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5\V ^ 




NEW WORKS 

ON 

ANATOMY, MEDICINE, SURGERY, CHEMISTRY, 
NATURAL HISTORY AND BOTANY. 

PUBLISHED BY H. BAILLIERE, 

219, REGENT STREET. 

G. R. WATER HOUSE, ESQ. 

A Natural History of the Mammalia. By G. R. Waterhouse, Esq., 
of the British Museum. Vol. I. Containing the Order Marsupiata, or 
pouched Animals, with 22 Illustrations, engraved on steel, and 18 
engravings on wood. Royal 8vo. price, elegantly bound in cloth. 
Coloured Plates, Ms. 6d. Plain, 29*. 

The Natural History of Mammalia is intended to embrace an account 
of the structure and habits of all the known species of Quadrupeds, or 
Mammals; to which will be added, observations upon their geographical 
distribution and classification. Since the fossil and recent species illustrate 
each other, it is also intended to include notices of the leading characters of 
the extinct species. 

The Genera, and many of the species will be illustrated by engravings on 
steel, and by vjood-cuts. Of the latter, between fifteen and sixteen hundred 
figures are executed. The modifications observable in the structure of the 
skulls, teeth, feet, and other parts, will be almost entirely illustrated by 
steel engravings. 

The work will continue to be published in monthly parts. Price, coloured, 
3s. plain, 2s. Qd. each. 

ALEXANDER VON HUMBOLDT. 

Kosmos : a General Survey of the Physical Phenomena of the Universe. 

By Baron A. Humboldt. The Original Translation. Vol. I. post 8vo. 

London, 1845. 10s. 
Vol. II. in the press, and from the assurance of the author, it 

may be expected to be ready in the course of the ensuing winter. 



JULIUS VOGEL, M.D., & G. E. DAY, M.D. 

The Pathological Anatomy of the Human Body. By Julius Vogel, M.D. 
Translated from the German, with additions from George E. Day, M.D. 
Illustrated by upwards of One Hundred plain and coloured Engravings. 
8vo. cloth. London, 1847. 18s. 



2 



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BENJAMIN PHILLIPS, F.R.S, 

Scrofula ; its Nature, its Prevalence, its Causes, and the Principles of 
Treatment. By Benjamin Phillips, F.R.S. , Assistant Surgeon and Lecturer 
on Surgery to the Westminster Hospital, 1 vol. 8vo. with an engraved 
Plate. London, 1846. 12s. 

"This is one of the few books which may be said to be after the critics own heart. 
It is a book that was wanted; the object of it is excellent, it has been carefully 
planned; the investigations required by the plan have been conducted with the utmost 
energy, industry and carefulness, in a sufficiently extensive field and over a sufficiently 
long period of time ; the immense mass of materials thus obtained has been examined 
and weighed with the greatest attention and impartiality j the inferences and results 
have been honestly and cautiously deduced and elaborated, and condensed into the 
smallest possible space consistent with perspicuity ; while the whole style and manner 
of the composition is such as ought to characterise the production of a well-educated, 
a learned and an experienced surgeon." — British and Foreign Medical Review. 



ROBERT E. GRANT, M.D. F.R.S. L. & E. 

General View of the Distribution of Extinct Animals. ■ By Robert E. 
Grant, M.D. F.R.S. L. & E. Professor of Comparative Anatomy, in the 
University College, London. In the " British Annual," 1839. 18mo. 
London, 1839. 3s. 6d. 

On the Principles of Classification as applied to the Primary Divi- 
sions of the Animal Kingdom. In the " British Annual," 1838. 18mo. 
Illustrated with 28 Woodcuts. London, 1838. Ss. 6d. 

Outlines of Comparative Anatomy. 8vo. Illustrated with 148 Wood- 
cuts. London, 1835—41. In boards, £1. 8s.— Part VII. with Title-page 
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MARSHALL HALL, M.D. F.R.S. L. & E. 

On the Diseases and Derangements of the Nervous System, in their 
Primary Forms, and in their Modifications by Age, Sex, Constitution, Here- 
ditary Predisposition, Excesses, General Disorder, and Organic Disease. 
By Marshall Hall, M.D. F.R.S. L. & E. 8vo. with 8 Plates, engraved. 
London, 1841. 15s. 

* As an Appendix to the above Work. 
On the Mutual Relations between Anatomy, Physiology, Pathology, 

Therapeutics, and the Practice of Medicine ; being the Gulstonian Lectures 

for 1842. 8vo. with 2 coloured Plates and 1 plain. London, 1842. 5s. 
New Memoir on the Nervous System, True Spinal Marrow, and its 

Anatomy, Physiology, Pathology, and Therapeutics. 4to. with 5 engraved 

Plates. London, 1843. £l. 



W. C. HUFELAND, M.D. 

Manual of the Practice of Medicine, the Result of Fifty Years' Ex- 
perience. By W. C. Hufeland, Physician to the late King of Prussia, 
Professor in the University of Berlin. Translated from the Sixth German 
Edition, by C. Bruchhausen and R. Nelson. 8vo. bound, London, 1844. 15s. 



ROBERT LEE, M.D. F.R.S. 

The Anatomy of the Nerves of the Uterus. By Robert Lee, M.D. F.R.S. 
folio, with 2 engraved plates. London, 1841. 8s. 



3 



GERBER AND G. GULLIVER. 

Elements of the General and Minute Anatomy of Man and the Mammalia. 
Chiefly after Original Researches. By Professor Gerber* To which is added 
an Appendix, comprising Researches on the Anatomy of the Blood, Chyle, 
Lymph, Thymous Fluid, Tubercle, and additions by C. Gulliver, F.R.S. 
In 1 vol. 8vo. Text, and an Atlas of 34 Plates, engraved by L. Aldous. 
2 vols. Svc!., 1842. Cloth boards. £1. 4s. 



R. T. H. LAENNEC. 

A Treatise on the Mediate Auscultation, and on Diseases of the Lungs and 
Heart. By R. T. H. Laennec, Professor to the College of France and to 
the Faculty of Medicine of Paris. With Notes and Additions by M. Laennec, 
and M. Andral, Professors to the Faculty of Medicine, Paris. Translated j 
from the last edition by a Member of the College of Physicians. Edited by 
Theophilus Herbert, M.D., with Practical Notes, condensed from the 
Lectures of F. H. Ramadge, M.D., Oxon. 8vo. with plates. London, 1846. 
18*. 

W. C. L. MARTIN, ESQ. 

A General Introduction to the Natural History of the Mammiferous 
Animals : with a particular View of the Physical History of Man, and the 
more closely allied Genera of the Order " Quadrumana," or Monkeys. 
Illustrated with 296 Anatomical, Osteological, and other Engravings on 
Wood, and 12 full-plate Representations of Animals, drawn by W. Harvey. 
1 vol. 8vo. London, 1841. 16s. 

RICHARD OWEN, F.R.S. 

Odontography; or, a Treatise on the Comparative Anatomy of the Teeth: 
their Physiological Relations, Mode of Development, and Microscopical 
Structure in the Vertebrate Animals. By Richard Owen, F.R.S. Cor- 
respondent of the Royal Academy of Sciences, Paris and Berlin : Hun- 
terian Professor to the Royal College of Surgeons, London. This splendid 
Work is now completed, 2 vols, royal 8vo. containing 168 Plates, half 
bound russia. London, 1840 — 45. £6. 6s. 

A few copies of the Plates on India paper, 2 vols. 4to. £10. 10*. 



J>. RAYER, M.D. 

A Theoretical and Practical Treatise on the Diseases of the 
Skin. By P. Rayer, M.D. Physician to the Hopital de la Charite. 
Translated by R. Willis, M.D. Second Edition, remodelled aud much 
enlarged, in 1 thick vol. 8vo. of 1300 pages, with Atlas, royal 4to. of 26 
Plates, finely engraved and coloured with the greatest care, exhibiting 400 
Varieties of Cutaneous Affections. £4. 8*. London, 1835. The Text 
separately, 8vo. in boards. £1. 8s. The Atlas 4to. separately, in boards, 
£3. 10*. 

J. CRUVEILHIER AND C. BONAMY. 

Atlas of the Descriptive Anatomy of the Human Body. By J. I 

Cruveilhier, Professor of Anatomy to the Faculty of Medicine, Paris. With j 

Explanation by C. Bonamy. Containing 82 4to. Plates of Osteology, |i 

Syndemology, and Myology. London, 1844. Plain, £3 ; coloured, £5. 15*. |j 



4 



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J. LEBAUDY, M.D. 

The Anatomy of the Regions interested in the Surgical Operations per- 
formed upon the Human Body, with Occasional Views of the Pathological 
Conditions, which render the interference of the Surgeon necessary, in a 
Series of 24 Plates, the Size of Life. By J. Lehaudy. Folio. London, 
1835. £\. 4s. 



Prof. J. SYME, F.R.S.E. 

Principles or Surgery. By J. Syme, Professor of Clinical Surgery in the 
University of Edinhurgh. Third edition, much enlarged, and illustrated I 
with 14 Plates on India paper, and 64 woodcuts. 1 vol. 8vo. London, 1842. 
£1.1 . 



JAMES WARDROP, M.D. 

On Blood-Leiting, an Account of the Curative Effects of the ahstraction of 
Blood ; with Rules for employing both local and general Blood-Letting in 
the treatment of Diseases. 12mo. London, 1835. 4s. 



ROBERT WILLIS, M.D. 

Illustrations of Cutaneous Disease : a Series of Delineations of the 
Affections of the Skin, in their more interesting and frequent Forms : with 
a Practical Summary of their Symptoms, Diagnosis, and Treatment, in- 
cluding appropriate Formulae. By Robert Willis, M.D. Member of the 
Royal College of Physicians. The Drawings are after Nature, and Litho- 
graphed by Arch. Henning. These Illustrations are comprised in 94 
Plates, folio. The Drawings are Originals, carefully coloured. Bound 
in cloth, lettered, London, 1842. 61. 

On the Treatment of Stone in the Bladder, by Medical and Mecha- 
nical Means. 8vo. London, 1 843. 5s. 



ROBERT WILLIAMS, M.D. 

Elements of Medicine : Morbid Poisons. By Robert Williams, M.D. 
Physician to St. Thomas's Hospital, 2 vols. 8vo. London, 1836—1841. 
£1. 8s. 6d. 

• Vol. 2. Separately. 1841. 18s. 



FRANCIS B. COURTENAY, ESQ. 

On the Pathology and Cure of Stricture in the Urethra. Illus- 
trating, by a selection from numerous interesting facts and cases, the 
Origin, Progress, and History of this Disease, in all its Phases, and em- 
bracing every variety of Morbid Contraction to which the Urethra is 
liable, together with an account of the mode of Treatment successfully 
adopted in each case, and Cure of every species of Urethral Stricture. 
Third Edition. 8vo. London, 1845. bs. 

Practical Observations on the Chronic Enlargement of the Prostate 
Gland in Old People, with Mode of Treatment. Containing numerous 
cases and plates. 8vo. in boards. London, 1839. 7s. 6d. 



219, REGENT STREET. 



5 



D. SPILL AN, M.D. 

Thesaurus Medicaminum ; or the Medical Prescriber's Vade-Mecum ; con- 
taining all the Medicinal Substances of the Pharmacopoeia, arranged 
according to their Therapeutic Action, with the most elegant method of 
prescribing each; to which are subjoined a Table of Incompatible Sub- 
stances, and Directions for the Treatment of Poisoning. By D. Spillan, 
M.D. 18mo. London, 1842. 3s. 

MICHAEL RYAN, M.D. 

The Philosophy of Marriage, in its Social, Moral, and Physical Rela- 
tions ; with an Account of the Diseases of the Genito-Urinary Organs, 
with the Physiology of Generation in the Vegetable and Animal Kingdoms. 
Fourth edition, very much improved. By M. Ryan, M.D. 1 vol. 12mo. 
London, 1843. 6s. 

ALFRED BEAUMONT HADDOCK, M.D. 

Practical Observations on the efficacy of Medicated Inhalations in the 
Treatment of Pulmonary Consumption. By Dr. Maddock. 8vo. with a 
coloured plate, 3rd edition. London, 1846. 5s. 6d. 

JAMES WILSON. 

Practice of the Water Cure, with authenticated Evidence of its Efficacy 
and Safety. Part L, containing seventy authenticated Cases, the Opinions 
of English Medical Practitioners, a Sketch of the History and Progress 
of the Water Cure, and an Account of the Processes used in the Treatment. 
8vo. London, 1844. Is. 6d. 

A. B. GRANVILLE, M.D. F.R.S. 

Kissingen, its Sources and Resources, with Observations on their use and 
efficacy in the Treatment of Diseases. By A. B. Granville, M.D. F.R.S. 
1 vol. 12mo. London, 1846. 5s. 

BARON JUSTUS LIEBIG. 

Chemistry and Physics, in relation to Physiology and Pathology. By 
Baron Justus Liebig, Professor of Chemistry at the University of Giessen. 
8vo. London, 1846. 3s. 

THE STARS AND THE EARTH. 

The Stars and the Earth ; or, Thoughts upon Space, Time, and 
Eternity. 18mo. London, 1846. Is. 

J. MULLS R, M.D. 

Elements of Physics and Meteorology. Illustrated by 541 Woodcuts. 
Translated from the German. London, 1847. (In the Press.) 

J. B. BOUSSINGAULT. 

Rural Economy, in its Relations with Chemistry, Physics and Meteorology. 
By J. B. Boussingault, Member of the Institute of France. With Notes. 
Second Edition, carefully revised and corrected, 1 vol. 8vo. 1845. Lon- 
don, 1845. Cloth boards. 18*. 



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J. DUMAS & J. B. BOUSSINGAULT. 

The Chemical and Physiological Balance of Organic Nature: 
j an Essay. By J. Dumas and J. B. Boussingault, Members of the Institute 
: of France. 1 vol. 12mo. London, 1844. 4s. 

PROFESSOR T. GRAHAM, F.R.S. 

i Elements of Chemistry ; including the Application of the Science in the 
Arts. By T. Graham, F.R.S. L. & E. Professor of Chemistry at Uni- 
versity College, London. Second Edition. Entirely revised and greatly 
enlarged. Part I. London, 1847. 5*. 
Part 6 & last of 1st Edition, containing Organic Chemistry, 8vo. 9s. 

R. D. THOMSON, MD. 

British Annual and Epitome of the Progress of Science. By 
R. D. Thomson, assistant Professor University of Glasgow, 3 vols. 18mo. 
cloth boards, lettered. 3s. 6d. each. 

First Year, 1837. 

Contains numerous Practical Tables of Weights, Measures, and Coins. The 
popular papers are by the Rev. B. Powell, C. Tomlinson, Esq., W. S. B. 
Waterhouse, Esq., T. S. Davies, Esq., R. D. Thomson, M.D. 

Second Year, 1838. 
The popular Papers are by T. Thomson, M.D. Regius Professor of Chemistry 
in the University of Glasgow, R. E. Grant, M.D., Professor of Comparative 
Anatomy in the University College, London, R. D. Thomson, M.D. Life of 
James Watt, illustrated with a Portrait. H. H. Lewis, Esq. 

Third Year, 1839. 

The Popular Papers are by J. S. Russell, Esq., Professor R. E. Grant, H. Gar- 
nier, Esq., R. D. Thomson, M.D. 

THOMAS THOMSON, M.D. F.R.S. L. & E. 

; Chemistry of Organic Bodies — Vegetables. By Thomas Thomson, M.D. 
I F.R.S. L. & E. Regius Professor of Chemistry in the University of Glasgow, 

Corresponding Member of the Royal Academy of Paris. 1 large vol. 8vo. 

of 1092 pages. London, 1838. Boards, 1/. 4*. 
j Heat and Electricity. Second Edition, 1 vol. 8vo. illustrated with 
| wood-cuts. London, 1839. 15s. 



PROFESSOR KiEMTZ. 

A Complete Course of Meteorology. By Ksemtz, Professor of Physics 
at the University of Halle. With Notes by Ch. Martins, and an Appendix 
by L. Lalanne. Translated, with Additions, by C. V. Walker, Editor of 
the " Electrical Magazine." 1 vol. post 8vo. (pp. 624), with 15 Plates, 
cloth boards. 1845. 12s. 6d. 



G. F. RICHARDSON, ESQ. 

Geology for Beginners; comprising a Familiar Exposition of the Ele- 
ments of Geology and its Associate Sciences — Mineralogy, Fossil Concho- 
logy, Fossil Botany, and Paleontology. By G. F. Richardson, F.G.S. 
Second Edition, with 251 Woodcuts. Post 8vo. 1843. 10s. 6d. 



219, REGENT STREET. 7 



JOHN MITCHELL, ESQ. 

Manual of Practical Assaying, intended for the use of Metallurgists, 
Captains of Mines, and Assayers in General. With a copious Table, for 
the purpose of ascertaining in Assays of Gold and Silver the precise amount, 
in Ounces, Pennyweights, and Grains, of noble Metal contained in one ton 
of Ore from a given quantity. By John Mitchell, Esq. Member of the 
Chemical Society of London, 1 vol. post 8vo. in cloth boards, London, 
1846. 10*. 6d. 

General Contents. 

Chap. I. On the mechanical and chemical operations of assaying. — Chap. II. 
Furnaces, fuel, crucibles. — Chap. III. The fluxes, their composition, mode 
of preparation and use. — Chap. IV. On the blow-pipe and its use — Discri- 
mination of minerals — General routine of blow-pipe operations — On the 
indications given by the most common of the minerals on being treated by 
the blow-pipe aided by fluxes. — Chap. V. Minerals of all the common 
metals, their composition, and method of determining their contents by 
humid analysis. — Chap. VI. — The assay of iron. — Chap. VII. Assay of 
copper ores. — Chap. VIII. The Assay of lead ores. — Chap. IX. Assay of 
tin ores. — Chap. X. Assay of antimonial ores. — Chap. XI. Assay of chro- 
mium ores. — Chap. XII. Assay of zinc ores. — Chap. XIII. Assay of mer- 
curial ores. — Chap. XIV. Assay and analysis of platinum ores. — Chap. XV. 
Assay of silver ores. — Chap. XVI. Assay of gold. — Chap. XVII. Assay 
and analysis of fuel. — Chap. XVIII. Assay Table, showing the amount of 
gold or silver, in ounces, pennyweights, and grains contained in a ton of 
ore, from the weight of metal obtained in an assay of 200 grains of mineral. 



JAMES C. PRICHARD, M D. F.R.S. 

The Natural History of Man ; comprising Inquiries into the Modi- 
fying Influence of Physical and Moral Agencies on the different Tribes of 
the Human Family. By James Cowles Prichard, M.D. F.R.S. M.R.I.A. 
Corresponding Member of the National Institute, of the Royal Academy 
of Medicine, and of the Statistical Society of France ; Member of the 
American Philosophical Society, &c, &c. Second Edition, enlarged, with 
44 coloured and 5 plain Illustrations, engraved on Steel, and 97 Engra- 
vings on Wood. Royal 8vo. London, 1845. Elegantly bound in cloth, 
£11. 13s. 6d. 

Appendix to the First Edition of the Natural History of Man. With 6 

coloured Plates. Large 8vo. London, 1845. 3s. 6d. 
Six Ethnographical Maps, as a Supplement to the Natural History of 

Man, and to the Researches into the Physical History of Mankind. Folio, 

coloured, and one sheet of Letter-press. London, 1845. 1/. Is. ; done up 

in cloth boards, 1/. As. 
Illustrations to the Researches into the Physical History of Mankind. 

Atlas of 44 coloured and 5 plain Plates, engraved on Steel. Large 8vo. 

London, 1841. Half bound, 18s. 
On the Different Forms of Insanity in relation to Jurisprudence. 

(Dedicated to the Lord Chancellor of England.) 12mo. London, 1842. 5s. 



PROFESSOR F. KNAPP. 

Chemical Technology. By F. Knapp, Professor at the University of 
Giessen. Illustrated with 400 large wood-cuts. Translated and Edited 
by Doctor Thomas Richardson, 1 vol. 8vo. London, 1846. (In the Press.) 



8 



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EDWARD J. CHAPMAN, ESQ. 

A Brief Description of the Characters of Minerals; forming 
a familiar Introduction to the Science of Mineralogy, by Edward J. 
Chapman, 1 vol. 12mo. with 3 plates, London, 1844. 4*. 

Practical Mineralogy ; or a Compendium of the distinguishing Cha- 
racters of Minerals ; by which the name of any species or variety in the 
mineral kingdom may be speedily ascertained. Illustrated with 13 en- 
gravings, showing 270 specimens, by Edward J. Chapman, 8vo. London, 
1843. 7*. 



H. G. OLLENDORFF, 

A New Method of Learning to Read, Write and Speak, the German Lan- 
guage in Six Months. Translated from the Fifth French Edition. By G. 
J. Bertinchamp, A.B. Second Edition, Revised and Considerably Im- 
proved, by James D. Haas. 12mo. Bound. 1844. 9s. 

also : 

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M. BONIFACE. 

Modern English and French Conversation. Containing Elementary 
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18mo. London, 1845. 3s. 



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SIR W. J. HOOKER. 

Icones Plantarum ; New Series. Vols. I — III, containing each 100 Plates 
with explanations. By Sir W. J. Hooker, Director of the Royal Botanical 
Gardens, Kew. 8vo. cloth. London, 1842 — 44. £\. 8s. each vol. — VoL 
IV. Part I. 14s. London, 1845. 

The London Journal of Botany. Vols. I — IV, with 24 Plates each, 
boards, 1842—45. £1. 10s. each vol. 

Also published monthly, with 2 plates. Price 2s. 6d. 

Notes on the Botany of the Antarctic Voyage conducted by Capt. James 
Clark Ross, R.N. F.R.S., in H.M.SS. Erebus and Terror ; with Observa- 
tions on the Tussac Grass of the Falkland Islands. 8vo. with 2 coloured 
Plates. London, 1843. 4s. 



ARTHUR HILL H AS S ALL, F.L.S. 

A History of the British Fresh Water Algae, including Descriptions of the 
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illustrating the various species; By A. H. Hassall. 2 vols. 8vo. cloth. 
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H. B. FIELDING, F.L.S. & F.G.S., & GEORGE GARDNER, F.L.S. 

Sertum Plantarum ; or, Drawings and Descriptions of Rare and undes- 
cribed Plants from the Author's Herbarium. By H. B. Fielding, assisted 
by G. Gardner, Superintendent of the Royal Botanic Gardens, Ceylon. 
8vo. London, 1844. £1. Is. 



ROBERT WIGHT, M.D. F.L.S. 

Illustrations of Indian Botany; or, Figures Illustrative of each of the 
Natural Orders of Indian Plants, described in the Author's Prodromus 
Florae Peninsulas Indiae Orientalis; but not confined to them. By Dr. 
Robert Wight, F.L.S., Surgeon to the Madras Establishment. Vol. I. 
published in 13 Parts, containing, 95 col. plates, Madras, 1838 — 40. 
£4 17*. 6d. Vol. II, Part I, coutaining 39 coloured plates, Madras, 1841. 
£1 5s. 

(Odd Parts can be obtained to complete seis.J 

Icones Plantarum Indiae Orientalis ; or, Figures of Indian Plants. By Dr. 
Robert Wight, F.L.S., Surgeon to the Madras Establishment. Vol. I. 4to. 
consisting of 16 Parts, containing together 318 plates, Madras, 1838 — 40. 
£4. Vol. II, consisting of 4 Parts, containing together 318 plates, 
Madras, 1840—42. £5 5s. Vol. III. Parts I— III, with 409 plates, 
Madras, 1843—46. £4 5s. 

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Contributions to the Botany of India. By Dr. Robert Wight, F.L.S., 
Surgeon to the Madras Establishment, 8vo. London, 1834. 7s. 6d. 

Spicilegium Neilgherrense ; or, a Selection of Neilgherry Plants, Drawn 
and Coloured from Nature, with Brief Descriptions of each ; some General 
Remarks on the Geography and Affinities of Natural Families of Plants, and 
Occasional Notices of their Economical Properties and Uses. By Dr. 
Robert Wight, F,L.S., Surgeon to the Madras Establishment. 4to. With 
50 coloured plates. Madras, 1846. £1 10s. 

Prodromus Floras Peninsulas Indiae Orientalis. Containing Abridged 
Descriptions of the Plants found in the Peninsula of British India, arranged 
according to the Natural System. By Drs. Robert Wight, F.L.S., and 
Walker-Arnott. Vol. I. 8vo. London, 1834. 16*. 



WORKS ON HOMCEOPATHY. 



J. BELLUOMINI, M.D. 

Scarlatina and its Treatment on Homoeopathic principles, By J. Belluomini, 
M.D. 8vo. London, 1843. 1*. 



BCENNINGHAUSEN. 

The Homoeopathic Treatment of Intermittent Fevers. By Bcenninghausen. 
8vo. New York, 1845. 2s. 6d. 




WORKS PUBLISHED BY II. BAILLIERE. 



British Journal of Homceopathy. Edited by Drs. Drysdale, Russel, 
and Dudgeon. Nos. 1 to 9, Price each 3s. 6d. Nos. 10 to 14, Price 
2s. 6d. Nos. 15 to 18, Price 4s. London, 1843 — 46. Published quarterly. 



P. F. CURIE, M.D. 

Annals of the London Homoeopathic Dispensary. 1 vol. 8vo. 20 

Nos. 1841—42. 15s. 
Practice of Homoeopathy. 1 vol. 8vo. London, 1838. 6s. 
Principles of Homceopathy. 1 vol. 8vo. London, 1837. 5s. 
Domestic Homoeopathy. Third Edit. 12nio. London, 1844. 5s. 

See Jahr. 



CURTIS AND LIIjIiIE. 

An Epitome of Homceopathetic Practice. Compiled chiefly from Jahr, 
Ruckert, Beauvais, Bonninghausen. 12mo. New York, 1843. 5s. 



J. GUNTHER, ESQ. 

New Manual of Homoeopathic Veterinary Medicine ; or, the 
Homoeopathic Treatment of the Horse, the Ox, the Dog, and other 
domestic animals. Translated from the third German edition, with 
considerable additions and improvements, post 8vo. cloth. London, 
1847. 10s. 6d. 



HARRIS DUNSFORD, M.D. 

The Practical advantages of Homceopathy, illustrated by numerous 
Cases. By H. Dunsford, M.D. Dedicated by permission to Her Majesty 
Queen Adelaide. 1 vol. 8vo. boards. 1841. 8s. 

The Pathogenetic Effects of some of the principal Homoeopathic Remedies. 
By H. Dunsford, M.D. 8vo. London, 1838. 9s. 



REV. T. R. EVEREST. 

A Populal View of Homceopathy, exhibiting the Present State of the 
Science. By the Rev. T. R. Everest. 2d edit, amended and much enlarged. 
8vo. London, 1836. 6s. 



G. H. G. JAHR. 

New Manual of Homceopathic Medicine. By G. H. G. Jahr. From the 
j third original edition, with Notes and Preface by Dr. P. Curie. In 
2 vols, post 8vo. London, 1847. 

See Curie. 

Short Elementary Treatise upon Homceopathy and its Practice, with some of 
the most important effects of Ten of the Principal Homoeopathic Remedies 
By G. H. G. Jahr. Translated by Boyard, M.D. 18mo. London, 1846. 
2s. 6d. 

New Homceopathic Pharmacopoeia and Posology, or the Preparation of i 
Homoeopathic Medicines. 8vo. Philadelphia, 1842. 12s. 



219, REGENT STREET. 11 



SAMUEL HAHNEMANN, M.D. 

The Chronic Diseases, their Specific Nature and Homoeopathic Treatment 

By S. Hahnemann. Translated and Edited by Charles J. Hempel, M.D. 

5 vols. 8vo. New York, 1846. £2. 
Organon of Homoeopathic Medicine. Second American, from the Biitish 

Translation of the Fourth German Edition. 8vo. cloth. New York, 1843. 

10s. 6d. 

Materia Medica Pura. By Samuel Hahnemann. Translated and Edited 
by Charles J. Hempel, M.D. 2 vols. 8vo. New York, 1846. 16s. 



J. RUOFF, M.D. 

Exposition de la Doctrine Medicale Homeopathique ou Organon de l'Art de 

Guerir. Par Leon Simon. 3eme Edition. 8vo. Paris, 1845. 8s. 
Doctrine et Traitement Homeopathique des Maladies Chroniques. Traduit 

de l'Allemand, par Jourdan, M.D. 3 vols. 8vo. Paris, 1846. £1. 3s. 
Traite de Matiere Medicale, ou de Taction pure des Medicamens Homeopa- 

thiques. Traduit de TAllemand, par Jourdan, M.D. 3 vols. 8vo. Paris, 

1834. £1 4s. 

Repertory of Homoeopathic Medicine Nosologically arranged. Translated 
from the German by A. H. Okie, M.D. with additions by G. Humphrey, 
M.D. 2nd Edition. 12mo. New York, 1845. Is, 



S. SIMPSON, M.D. 

A Practical View of Homoeopathy with Cases. By S. Simpson, M.D. 8vo. 
London, 1836. 10s. 6d. 



C. HEEINGj M.D. 

The Homcsopathist or Domestic Physician. By Charles Hering, M.D. 
(Philadelphia, U.S.) 2d Edition. 12mo. London, 1845. 7s. 



WORKS ON MESMERISM. 



JOHN ELLIOTSON, M.D. Cantab. F.R.S. 

The Harveian Oration, delivered before the RoyaHCollege of Physicians. 
London, June 27, 1846. By John Elliotson, M.D., Cantab., F.R.S., 
Fellow of the College, with an English Version and Notes. 8vo. London, 
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Numerous Cases of Surgical Operations without Pain in the Mes- 
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See Teste, Zoist. 

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W. C. ENGLEDUE, M.D. 

Cerebral Physiology and Materialism, with the Result of the Appli- 
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See Zoist. 



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Mesmerism in Disea.se; a Few Plain Facts, with a Selection of Cases. 
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Early Magnetism in its Higher Relations to Humanity. As veiled in the 
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A Practical Manual of Animal Magnetism ; containing an Exposition 
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THE 

PATHOLOGICAL ANATOMY 

OF THE 

HUMAN BODY. 



THE 



PATHOLOGICAL ANATOMY 



OF 

THE HUMAN BODY. 

BY JULIUS VOGEL, M.D. 

PROFESSOR OF CLINICAL MEDICINE AT THE UNIVERSITY OF GIESSEN. 

TRANSLATED FROM THE GERMAN WITH ADDITIONS, 

BY GEORGE E. DAY, M.A. & L.M. CANTAB. 

MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS ; PHYSICIAN TO THE WESTERN 
GENERAL DISPENSARY ; LECTURER ON HISTOLOGY AND ANIMAL CHEMISTRY 
AT THE MIDDLESEX HOSPITAL MEDICAL SCHOOL; MEMBER OF THE 
PATHOLOGICAL SOCIETY OF LONDON, AND FORMERLY SENIOR 
PRESIDENT OF THE ROYAL MEDICAL SOCIETY OF 
EDINBURGH. 



ILLUSTRATED BY UPWARDS OF ONE HUNDRED PLAIN AND COLOURED 

ENGRAVINGS. 



/ 

LONDON: 
H. BAILLIERE, PUBLISHER, 

FOREIGN BOOKSELLER TO THE ROYAL COLLEGE OF SURGEONS AND THE 
ROYAL-MEDICO CHIRURGICAL SOCIETY. 

PARIS : J. B. BAILLIERE, LIBRAIRE DE l'aCADEMIE ROYALE DE 
MEDECINE, RUE DE l'eCOLE DE MEDECINE. 



1847. 



LONDON: 

Printed l>y Schtilze & Co., 13, Poland Street. 



TO 



C. J. B. WILLIAMS, M.D. F.R.S. 

THE PRESIDENT ; 
TO 



h. GUY BABINGTON, M.D. F.R.S. 
KICHARD BRIGHT, M.D. F.R.S. 
JOHN CLENDINNING, M.D. F.R.S. 
JOHN FORBES, M.D. F.R.S. 



J. MONCRIEFF ARNOTT, ESQ. F.R.S. 
CAESAR HAWKINS, ESQ. 
C, ASTON KEY, ESQ. 
ROBERT LISTON, ESQ. F.R.S. 



THE VICE-PRESIDENTS ; 
AND TO 

JAMES COPLAND, M.D. F.R.S. 

THE TREASURER 
OF 

THE PATHOLOGICAL SOCIETY OF LONDON, 

WHOSE LABOURS IN MORBID ANATOMY AND PATHOLOGY 
HAVE ACQUIRED FOR THEM UNDYING NAMES IN 
THE RECORDS OF MEDICAL SCIENCE, 
THIS VOLUME IS DEDICATED 
WITH EVERY FEELING OF RESPECT 

BY THE EDITOR. 



TO THE READER. 



The entire absence of any English work on Morbid 
Anatomy, embracing the recent discoveries effected by 
Chemistry and the Microscope, affords a sufficient reason 
for the appearance, in the present form, of Vogel's 
Pathological Anatomy of the Human Body. 

This volume forms in itself a complete Treatise 
on general Morbid Anatomy. It will very shortly be 
followed by a second, devoted to the consideration of 
Pathological changes affecting special organs. 

The additions that I have made to this volume are 
trivial and unimportant, with the exception of the Plates 
and their explanations. These are almost entirely selected 
from the Author's " Icones Histologic Pathologies," and 
will, I trust, be found valuable aids to the clear under- 
standing of the subjects they are intended to illustrate. 

I gladly avail myself of this opportunity of expressing 
my obligations to Dr. Vogel, who has not only promised 
me a considerable amount of additional matter bearing 
on general Morbid Anatomy (which will appear in an 



XX 



TO THE READER. 



Appendix on the completion of the Work)', but has carefully 
examined a considerable portion of this volume, and 
expressed his satisfaction at the manner in which I have 
executed my task, I am likewise much indebted to my 
brother, Mr. E. Welby Day, for important assistance in 
preparing this volume for the press. 

George E. Day. 

3, SOUTHWICK STBEET, 
HYDE PARK. 



TABLE OF CONTENTS. 



Page 

Introduction. ...... 1 

The relations of pathological anatomy to the other depart- 
ments of medical science. .... 1 — 20 

CHAPTER I. 

ABNOKMAL DEVELOPMENT OF GASEOUS MATTERS PNEUMA- 
TOSES. . . . . . .21 

Causes of pneumatoses . . . ... 22 

From the external pressure of the atmospheric air . — 

From gases developed in the hody . . .25 

Development of gas from the decomposition of food in the intes- 
tinal canal . . . . .27 

Development of gas from the decomposition of the constituents of 

the body . . . . . .29 

The actual secretion of gas by different parts of the body . 31 

CHAPTER II. 

Abnormal collections of aqueous fluids — dropsies. 33 

1. Serous dropsy. . . . . .35 

Properties and chemical composition of the fluids occurring in 

serous dropsy . . . . .35 

Causes and mode of origin . . . .40 

Further progress of the dropsical fluid after its effusion . 43 

Its diagnosis and anatomical relations . . .44 

2. Fibrinous dropsy. . . . . .45 

Properties and chemical composition of this fluid . . 46 

Causes, mode of origin and further progress . . 49 

Its diagnosis and relation to the surrounding parts . . 56 

3. False dropsy. . . . . .57 



XXII 



TABLE OF CONTENTS, 



CHAPTER III. 

Page 



Pathological relations of the blood . . 59 

1 . Physical and chemical changes . . . 59 

Changes in colour . . . . .61 

Alterations in the colour of the serum . . .63 

Changes in its consistence . . . .64 

Deviations in the coagulation . . . .65 

The buffy coat . . . . . 68 

Changes in odour and taste . . . .70 

Changes in the blood-corpuscles , . . • — 

Increase or diminution of fibrin . ... .73 

Increase or diminution of blood-corpuscles . . .75 

Increase or diminution of water . . . .78 

Increase or diminution of albumen . • • — 

Increase or diminution of salts . . • .79 

Increase of urea . . . . .80 

Foreign matters in the blood . . . . — 

Free lactic acid . . . • • — 

Carbonate of ammonia . . . . . — 

Pyin, sugar, bile-pigment, pus-corpuscles, and entozoa . . 81 

The general changes of the blood . . . .82 

2. Changes in its quantity. . . .83 

General hyperemia . . . . .83 

General anaemia . . . . .85 

Local hyperemia . . . . . — 

Venous hypersemia . . . . . — 

Hyperemia of the capillaries . . . .86 

Congestion — Stasis . . . . .88 

Local anaemia . . . . .89 

3. Extravasation of blood. . . . .89 

4. Solution of hsematin and saturation of the tissues with it. 97 

CHAPTER IV. 

The general relations of pathological epigeneses . 99 

Distinction between organized and unorganized epigeneses . 100 

Unorganized formations . . . .101 

Organized pathological formations . . 1 05 

The cytoblastema . . . . . — 

The law of analogous formation . . . .115 

The cell theory . . . . .116 

Formation of cells . . . ' . .117 



TABLE OF CONTENTS 



xxiii 



Page 

Persistent cells . . . • .125 

Transitory cells . . . . • — 

Exceptions to the cell theory .... 127 
Classification of morhid epigeneses . . .131 



CHAPTER V. 



Special relations of pathological epigeneses. . 133 

Pus. . ..... 133 

1. True genuine pus. . . . . .134 

Pus-corpuscles . . . . .134 

Molecules in pus ..... 142 

Serum of pus or liquor puris .... 143 
Chemical composition of pus . . . .144 

Formation of pus . . . . . — 

Diagnosis of normal pus . . . .150 

Abnormal pus . . . . .152 

2. Spurious pus. . . . . .155 

Compound inflammatory globules — Granular cells . . 155 

Suppuration . . . . . .158 

Malignant suppuration . . . . .163 

Cause of the formation of granular cells . . . 164 

Resorption of pus — Metastatic abscesses . . . 165 

Solid pathological epigeneses. . . . .167 

Epigeneses of imperfectly organized structures. . .168 
Epigenesis of areolar (or cellular) tissue. . . 1 69 

Epigenesis of the blood and vessels. . . .174 

Epigenesis of epithelium and epidermis. . . .178 

Granulations. . . . . .179 

Epigenesis of fat and adipose tissue. . . .181 

Epigenesis of muscular tissue. . . . .184 

a. Striated muscle . . . . . — 

b. Non-striated muscle . . . .186 

Epigenesis of elastic tissue. . . . .186 

Epigenesis of granular pigment — melanosis. . . 1 89 

Epigenesis of nervous tissue. . . . .197 

Epigenesis of cartilaginous and osseous tissues. . . 198 

Tumours. . ..... 202 

Their classification and general relations. . . . 202 

Non- malignant tumours analogous to the normal elements of 

the body. . . . . . ... . 205 

First Group — Vascular Tumours . . .207 

Second Group — Fatty Tumours .... 209 



XXIV 



TABLE OF CONTENTS, 



Page 

Third Group — Fibrous Tumours . . . .215 

Fourth — Cartilaginous Tumours .... 224 
Fifth Group — Osseous Tumours . . . . 230 

Sixth Group — Melanotic Tumours . . .233 

Seventh Group — Gelatinous Tumours . . . 236 

Eighth Group— Encysted Tumours . . . 238 

Malignant heterologous tumours— Pseudoplasmata. . 261 

First Class. — Pseudoplasmata slightly or not at all organized. 270 
Typhous deposits . . . . .271 

Scrofulous deposits . . . . 274 

Tubercle . . . . . . 275 

Second Class. — Epigeneses of a more highly organized cha- 
racter. ...... 289 

Cancer . a .. . . . . 290 

Forms and varieties of cancer . . . .316 

First Form — Cellular cancer. Encephaloid . . . 317 

Second Form — Fibrous cancer. Scirrhus . . . 324 

Third Form — Melanotic cancer .... 330 

Fourth Form — Gelatinous cancer. Colloid . . . — 

Polypi and fungoid growths . . . 332 

Special relations of unorganized pathological epigeneses. . 333 

1. Precipitates of protein-compounds . . . 337 

2. of the fats . . . .339 

3. of uric acid and the urates . . . 342 

4. of the salts of lime .... 343 

5. of ammoniaco-magnesian phosphate . . 345 

6. of sulphuret of iron . . . 346 

7. of bile-pigment . . . . — 

8. of silica . . . . . — 

9. of various other substances . . .347 

Concretions. . . . . . .348 

First Class. — Concretions in the fluid secretions. . .348 

i. Urinary calculi. ..... 350 

Calculi of uric acid and the urates . . . 350 

of uric oxide ..... 355 

— of cystin . . . . .356 

of oxalate of lime . . • . . . 357 

of the earthy phosphates .... 358 

of organic matter . . . .359 

Alternating calculi . . . • .360 

Calculi formed in the generative organs . . . 362 

ii. Salivary concretions. . . . .363 
in. Lachrymal calculi. . . . .367 

iv. Concretions in the nostrils, throat, tonsils and bronchi. 368 

v. Pancreatic calculi. . . . . . 369 



TABLE OF CONTENTS. 



XXV 



Page 

vi.. Gall-stones- . . . . . 369 

vn. Intestinal concretions. .... 375 

viii. Concretions in the cutaneous glands. . .381 

Second Class. — Concretions in the parenchyma of organs. . 383 

CHAPTER VI. 

Pathological changes in the physical properties of 

the tissues and organs of the body . . 390 

1. Changes of colour. . . . . .391 

Abnormal paleness . . . . .391 

Abnormal redness ..... 393 
Dark coloration ..... 395 

Yellow coloration . . . . . — 

Green coloration ..... 396 

Blue coloration . . . . .397 

2. Changes of form and size. . . . .398 

3. Changes in the consistence of the various organs. . 404 

Hardening or induration .... 404 

Softening ...... 405 

Gangrene . . . . . 409 



CHAPTER VII. 

Combinations of morbid elementary changes. 
First Group — Venous hyperemia and serous dropsy 
Second Group — Capillary hyperemia and fibrinous dropsy 
Inflammation 

CHAPTER VIII. 



Independent organisms in the human body — parasites. 420 
Nature of parasites . . , . .421 

Equivocal generation . . . .422 

Relations of parasites to disease .... 424 

Parasites derived from the vegetable kingdom — epiphytes. . 426 

i. Fungi in human fluids. .... 430 

The yeast plant . . . . .430 

The sarcina ventriculi . . . . . 432 

ii. Fungi on the human integument and its appendages. . 433 

Fungi in the scrofulous scald-head, (Tinea favosa) . . 435 

Fungi in the sheath cf the hair in mentagra . . 436 



Fungi in the interior of the hair-roots in herpes tonsurans and in 
plica polonica . . . . 



412 
413 
414 
417 



xxvi 



TABLE OF CONTENTS. 



Page 

in. Fungi on mucous membranes. . . . 437 

Parasitic animals. . . . . .438 

i. Parasitic infusoria. . . . . . 440 

ii. Parasitic insects. ..... 443 

Fleas 

Lice. . . ... . . .444 

Bugs ...... 446 

in. Parasitic arachnida. .... 447 

The itch-mite . . . . .448 

The acarus of the human hair-sac . . . .453 

iv. Parasitic worms. . . . . . 454 

First Order. — Nematoidea. .... 455 

The guinea-worm . . . . . — 

The filaria oculi humani . . . .457 

The filaria bronchialis ..... 458 
The trichina spiralis . . . . ; 459 

The trichocephalus dispar . . . .461 

The tricocephalus affinis . . . . — 

The spiroptera hominis . . . . 462 

The strongylus gigas . . . . . — 

The ascaris lumbricoides . . ... — 

The ascaris alata . . . . .464 

The ascaris vermicularis . . . . — 

Second Order. — Trematoda. . . . .465 

The liver-fluke (distoma hepaticum) . . . — 

The distoma oculi humani . . . .466 

The poly stoma pinguicola . . . .467 

Third Order. — Cestoidea. . . . .467 

The common tape worm (taenia solium) . . . — 

The broad tape worm (bothriocephalue latus) . . 469 

Fourth Order. — Cystica. . . . ,471 

The cysticercus cellulosa . . . .471 

The echinococcus hominis . . . .473 

Acepholocysts — hydatids . . . .476 

Pseudoparasites. . . . . .478 



CHAPTER IX. 



Congenital modifications of the human body. — mal- 
formations. . 480 
Their causes 483 
Their classification , . , ' 437 



TABLE OF CONTENTS. 



XXV11 



Page 

First Class. — Malformations in which certain parts are entirely 

absent, or are too small. . . . .488 

First Order— Deficiencies, in the strict sense of the word . — 

Second Order — Abnormal diminutiveness of parts — dwarfish 

structure ...... 495 

Second Class. — Malformations from coalescence of organs. 496 
Third Class. — Malformations in which parts normally united 

are separated from each other — Fissures. . .501 

Fourth Class. — Malformations in which normal openings are 

closed — Atresia. . . . . .507 

Fifth Class. — Malformations of excess, or in which certain 

parts have a disproportionate size. . . .507 

First Order — One or more parts disproportionately large . 508 

Second Order — One or several supernumerary organs . — ■ 

Sixth Class. — Malformations in which one or many parts 

have an abnormal situation. . . .519 

Seventh Class. — Malformations of the generative organs — 

Hermaphroditism. . . . .520 

Eighth Class. — Malformations arising from morbid changes 

affecting the foetus, the placenta, and the membranes . 524 

CHAPTER X. 

Changes occurring in the body after death — post- 
mortem CHANGES. . ... 52G 

Explanation of the Plates. . . . .533 



ERRATUM. 



Page 133, Line 2, for Pathological epigeneses consisting of fluids with more or less orga- 
nized parts ; read Special relations of pathological epigeneses, 



} 



INTRODUCTION. 



The great object of works on the Anatomy of the Human 
Body in a state of health, is the description of the elemen- 
tary tissues and their properties, and of the manner in which 
these tissues are arranged and distributed so as to form the 
different organs ; further, to explain their mode of formation, 
and the manner in which the whole body is developed from 
them. The whole of these elementary textures, tissues, and 
organs are in each individual body essentially the same, 
although occasional differences present themselves, which if 
very striking, are described as varieties. 

The case, however, is different when a body, or a portion 
of it, which has suffered from disease is submitted to ana- 
tomical examination. Here deviations from the appearances 
presented by the healthy body are frequently observed. These 
deviations are very numerous in character ; sometimes the 
elementary textures are changed ; sometimes new formations 
foreign to the normal condition are introduced ; in some cases 
the position or form of some of the organs is changed ; whilst 
in others the deviation has reference merely to particular por- 
tions or elements of one or more organs. 

The knowledge and description of these changes, and the 
investigation of their origin and development constitute 
Pathological Anatomy, which, therefore, depends upon 
healthy anatomy as its natural basis ; the former embraces as 
its peculiar study precisely that which the latter rejects. From 

VOL. I. B 



2 



INTRODUCTION. 



the nature of the boundary between these two departments 
of anatomy, the question often arises — to which of the two cer- 
tain cases belong. Each draws its materials from the examina- 
tion of the dead body and its various organs ; one investigates 
healthy, the other diseased conditions. But the ideas of health 
and disease are very relative, and since no human organ presents 
the ideal of health in absolute perfection, it frequently be- 
comes questionable whether certain appearances ought to be 
regarded as appertaining to pathological or to healthy anatomy. 
When these dubious changes influence whole organs, or large 
parts of them, a precise decision is possible, but the farther 
the investigation is carried out in all minute details, so much 
the more difficult becomes the decision ; and it must be granted 
that there is a neutral ground, the indisputable property of 
neither department. 

The influence of our science on pathology is frequently 
misunderstood, being sometimes too lowly, sometimes too 
highly estimated; it consists essentially in the information 
which it communicates respecting the material changes in the 
different parts of the body which accompany or produce 
morbid symptoms. In showing how these morbid products 
are formed and gradually perfected, it assists pathology; and in 
elucidating the processes by which the affected part returns 
to its normal condition, it is subservient to therapeutics. To 
both of these departments of medicine, it yields an important 
part of the materials absolutely requisite for their firm 
establishment. They may be incomplete, and consequently 
susceptible of augmentation ; but if based on correct obser- 
vations, and free from hasty and incorrect conclusions, 
they will remain permanently valid. They have continued 
and will always continue the same, independently of the 
confirmation or subversion of any medical theory. 

Having thus shown the intimate connexion between 
pathological anatomy and the medical sciences in general, 
we will now notice its bearings in relation to the individual 
branches. 



INTRODUCTION. 



3 



Medicine has a double signification ; it is at once a science 
and an art. Medicine, as an art, has a practical value in 
relation to life, and is therefore regarded by the mass of its 
disciples as of the highest importance. But it is an error, and 
an indication of little intelligence to regard the practical as the 
only important part of medicine, and the scientific as a mere 
superfluous decoration, as a brilliant but useless ornament. There 
are crafts in which the manual dexterity acquired by long prac- 
tice seems to suffice for practical purposes independently of all 
scientific inquiry ; yet even in these cases, the immeasurable 
strides with which these arts have recently progressed, afford 
the most convincing proof that the application of scientific 
principles to even the simplest operations, which were supposed 
to be incapable of improvement, has been productive of the 
happiest results. In medicine such narrow views must be 
rejected, for they would tend to produce the blind self-esteem 
which regards ancient formulae and mechanically learned pro- 
cesses as sufficient to heal all diseases ; or else they would 
excite doubts regarding the whole science of medicine and 
deny its power in toto } because there are difficulties and 
obscurities which exceed its power of solution. Each of these 
views regarding the healing art is equally erroneous ; the 
directions for medical treatment given to us by the various 
schools are yet far from sufficient, and every conscientious 
physician will confess that those unworthy disciples of 
Esculapius, who, with self-sufficient confidence, publish their 
own methods of cure as alone true and infallible, are richly 
deserving of the scorn and contempt which satire from the 
earliest ages has heaped upon them. Equally mischievous 
and deplorable is medical scepticism. It is true that the 
science is yet far from being in a condition to answer all 
the intricate questions which the varied character of disease 
may suggest ; that time is still far distant, indeed it may 
never arise ; yet the science still remains, and confidence 
in its results is the sole prop on which the practice of the 
physician can rest. The consciousness that he has scrupu- 

b 2 



4 



INTRODUCTION. 



lously followed its indications, and so discharged his duty, is his 
only comfort, when in sadness he is constrained to confess the 
inutility of all his efforts. Above all, we must not be led away 
by such phrases as "practical views" and "medical experience" — 
terms of common use, and too often conveying an erroneous 
impression. The practical views of the physician are the 
result of a series of accurate observations elucidating the 
treatment of disease. The true physician may be distinguished 
from the empiric by this, that the latter is more or less 
unconscious of the grounds on which he acts ; and if the 
experience of the empiric seems in some few cases to be more 
successful than science, it can only be referred to a fortunate 
chance directing to the right point, and probably not based 
on the conscious experience of a single case. But science 
itself consists of the accumulated experience of individuals; 
and in proportion as that experience is limited (and especially 
when it is confined to a single individual) it follows from the 
very nature of the case that it cannot rest on a sufficiently 
broad scientific basis. In proportion as the science advances, 
and its cultivation is zealously carried on, so much the more 
w T ill practical views and experience become the common pro- 
perty of all physicians who combine theory and practice; 
and that which was formerly regarded as the exclusive property 
of the medical pioneer will be open to all — will be almost the 
common stock of all who strive to obtain it. 

It has been shown by long experience that scepticism 
in medicine leads, as it does in religion, to bigotry and 
superstition. It often leads its votaries to become the con- 
verts of one-sided unscientific systems, which having some 
semblance of truth, have at different periods been brought 
forward and supported, such as Humoralism, Solidism, Bruno- 
nianism, Iatrochemistry, Homoeopathy, Hydropathy, and the 
like, which after a short meteoric brilliancy have utterly disap- 
peared ; or, in better cases, after withdrawing their vaunting 
pretensions, have contributed the germs of truth which they 
contained to the great stock of medical knowledge. Confidence 



INTRODUCTION. 



5 



in true science is the best defence against this medical bigotry. 
He who takes a calm survey of the whole science is not 
likely to take up a one-sided system ; he who feels the incom- 
pleteness of the science will be in little danger of glorying in 
the perfection of his knowledge, or of proclaiming the infalli- 
bility of his practice. 

The above observations apply equally to every part of 
medical science. The relation in which pathological anatomy 
stands to the sister science is still more striking. 

The human organism is wonderfully constructed, being 
infinitely more complicated and delicate than the most per- 
fect mechanism ever designed by the human intellect. It 
consists of an infinite number of parts, fluid as well as solid, 
connected with each other in a wondrous manner. The branches 
of medicine elucidating this structure are histology, anatomy, 
and animal chemistry. The various parts of the human 
organism are in a state of continuous activity, and stand in 
various relations both to each other and to the external world. 
Hence are developed those mysterious vital phenomena which 
physiology has in vain attempted to unravel. But these vital 
phenomena are by no means uniform in their character ; they 
present the most striking contrasts in different individuals, 
and even in the same individual at different periods, and the 
relative proportions of the various parts and systems of the 
organism are, even in the normal condition, for ever fluc- 
tuating. 

The idea of normal life is, therefore, extremely indefinite, 
and it is only by a forced abstraction that the normal can 
be separated from the abnormal. 

Hence also the idea of disease is very indefinite ; it cannot 
be separated by any well-defined boundary from the idea of 
normal life, and the two conditions are connected by a species 
of debateable border land. It is not a mere deviation from 
the normal condition which constitutes disease, for that condi- 
tion is of itself variable ; but it must be productive of injury to 
the organism before it can be ranked as disease. The extent 



6 



INTRODUCTION. 



and degree of this injury is again most variable. From those 
grave injuries which rapidly terminate in death, down to the 
slightest form of disturbance, hardly worthy of the term 
disease, how infinitely multiplied are the varieties. Hence, in 
this point of view, disease is not strictly distinguishable from 
the normal state. 

The idea of disease must also be considered in a different 
point of view. A disease is not, as many believe, a self- 
existing entity ; it consists rather in a change in the vital pheno- 
mena of an organism ; it is no more an independant organism, 
or even pseudo-organism, than are the separate states or vital 
indications of an organism, such as walking, sleeping, eating, or 
speaking. Diseases may in different cases present the greatest 
varieties; each vital indication of an organism, every process 
connected with life may, in various ways, either alone or in 
combination with other processes, assume a morbid condition. 
Hence diseases will not admit of the same species of classifica- 
tion as if they were peculiar organisms, such as animals or 
plants : organisms, like diseases, are generally complex in their 
character, but in every animal and vegetable species all the 
individuals are, with very trifling deviations, composed of the 
same parts, while there are hardly two cases of disease in 
which the symptoms are precisely identical. And when, for 
convenience in teaching, such a classification is adopted, we 
must bear in mind that it is, and ever must be, an 
imperfect and arbitrary one, and not based on any natural 
system. 

As the normal condition of the vital processes is dependant 
on the normal condition of the individual parts of the body, 
and on the proper discharge of their various functions, so 
disease arises when portions of the body deviate from their 
normal character, and either cease to discharge their functions 
at all, or discharge them in an abnormal manner. These 
morbid changes, affecting the functions of the body, are very 
frequently dependant on material changes, perceptible to the 
eye, and recognized by the feelings. These material changes 



INTRODUCTION. 



7 



(in the widest sense of the term) form the domain of patho- 
logical anatomy. 

It is not, however, in all diseases that we can, at least in 
the present state of our knowledge, recognise such material 
changes. Hence there are diseases to which pathological 
anatomy seem to have no application. There are many 
transitory morbid changes in the vital phenomena, dependant 
on the nervous system, which appear and vanish without 
leaving a material change capable of detection by the most 
zealous investigator. Certain changes probably have occurred, 
but were unsuspected at the time, and hence, in a scientific point 
of view, yielded no result. In other cases, diseases seem to pro- 
duce appreciable changes, not on the solid organized parts, but 
on the fluids, impressing upon them certain chemical changes 
either of a qualitative or quantitative character : whether these 
are to be regarded as appertaining to pathological anatomy, 
must be a matter of opinion. As anatomy is usually consi- 
dered to embrace the theory of the constituent parts of the 
human body in relation to form and composition, so patholo- 
gical anatomy ought to include deviations in chemical 
composition : there seems, however, to have been a tendency 
lately to regard this class of changes as belonging to a 
separate science to which the term Pathological Chemistry 
has been given. 

In addition to observing the material changes accompanying 
various diseases, it is likewise the object of pathological 
anatomy to investigate the causes which give rise to them, 
their development and gradual formation, and their conse- 
quences; but this can only be done as far as is consistent 
with certainty. This condition, therefore, is especially impor- 
tant in all that concerns pathological anatomy. Pathology, 
from its very nature, must often frame hypotheses, and 
must frequently be content with probabilities when certain 
truth is unattainable ; for the physician cannot suspend his 
practice in cases where he does not distinctly see his 
way, 



8 



INTRODUCTION. 



But it is otherwise with pathological anatomy, in which the 
immediate object in view is not the same as in practical medi- 
cine ; it must, therefore, restrict itself to positive knowledge, 
and must be always conscious of the degree of certainty 
which its conclusions warrant. And then, let the systems of 
medicine change as they may, the doctrines of pathological 
anatomy will stand unaffected. 

Almost every disease is made up of various disturbances, 
which often, to the detriment of science, as well as of the 
patient, are referred to a single morbid origin, and receive one 
common name. Pathological anatomy must not adopt this 
course ; its object must be, on the contrary, to separate each 
material change from all the rest ; to isolate it, follow it in its 
minutest details, and trace its causes and effects. It is not 
till this is accomplished that the relation of these changes to 
others is to be considered. By these means, and by these 
alone, can pathological anatomy arrive at certain truth, and 
gradually attain a position to assist in the construction of the 
medical sciences on a broad and sure foundation. Pathological 
anatomy is, therefore, a useful section of pathology, contri- 
buting to practical medicine, as it were, the solid materials 
from which to construct a basement, without having the 
power to erect a perfect edifice. And here is the point in 
which it differs from pathology — a point respecting which 
there are two common errors. Some have overstretched the 
true limits of pathological anatomy, and have included within 
them disturbances in the functions of the nervous system, and 
other morbid symptoms altogether foreign to its jurisdiction, 
and have endeavoured to elevate it to pathology. Others, on 
the contrary, have attempted to reduce pathology to patholo- 
gical anatomy, and to explain all morbid phenomena by 
recognized material changes, debasing the science of medicine 
into one-sided pathological solidism. 

The importance of pathological anatomy to the different 
branches of pathology varies considerably. It has always 
been of the greatest importance to surgery, principally in 



INTRODUCTION. 



9 



reference to visible changes in the position, size, and connexion 
of the different organs: hence the origin of the surgical depart- 
ment of pathological anatomy. The changes accompanying 
internal disease are less obvious to the eye. They require the 
finest dissection and microscopic observation, and then often 
evade detection; their causes and consequences are likewise 
very obscure. Hence the influence of pathological anatomy 
on this department of pathology is of, comparatively speaking, 
recent origin. We may here again repeat what has been 
already mentioned, that the pathology of the solids is that 
which will receive the greatest benefit from pathological 
anatomy, whilst in diseases of the nervous system, and in 
disordered conditions of the fluids, it will be of less ser- 
vice. 

Although at first sight it might appear that our subject was 
of small importance in relation to therapeutics, this is not in 
reality the case. Scientific treatment necessarily demands an 
extensive knowledge of the material changes which lie at the 
foundation of the various morbid symptoms. Hence patho- 
logical anatomy necessarily forms a portion of the positive 
basis of therapeutics ; and, farther than this, it points out the 
processes by which the different altered parts may be gradually 
restored to their normal condition. It not merely points out 
what requires healing, but in many cases, also, the course 
that must be adopted in order to aid the curative tendency 
of nature. It serves likewise as a check on therapeutics, 
exposing, in a most conclusive manner, the absurdity of many 
pretended methods of cure. It points out, for example, that 
in a certain stage of inflammation of the lungs, a fibrinous 
fluid separates from the blood, and by its coagulation renders 
a portion of the parenchyma of the lungs impermeable to air; 
and further, that it requires several days for this coagulated 
matter to reassume the fluid condition, and be removed. Now, 
if any one should assert that, in this stage of the disease, he 
could apply a remedy which would cure the patient in a few 



1 0 INTRODUCTON. 

hours, a very superficial knowledge of pathological anatomy 
would show the folly of such an assertion. 

Let us now turn to the means by which a knowledge of 
pathological anatomy may be attained. 

The study of those morbid changes to which the various 
parts of the body are liable, depends on a thorough previous 
knowledge of their normal relations ; hence pathological ana- 
tomy requires a perfect knowledge of the structure of the 
healthy body, and of a special department of physiology (de 
usu partium) in order to be able to estimate the influence 
which any morbid alteration of an organ impresses on its 
function. Our science must not merely study the coarser 
changes, such as are visible to the unaided eye ; but also those 
finer modifications affecting elementary tissues, visible only by 
the microscope ; hence the necessity for an accurate know- 
ledge of general anatomy or histology. Histology and 
descriptive anatomy are most intimately connected with 
pathological anatomy ; they unite to form the necessary data 
for its successful cultivation; and further, there exists a 
boundary in common to all three, which they simultaneously 
occupy and cultivate. Thus, for example, certain varieties in 
the form and position of different parts of the body, as of the 
vessels, may be ranged under either normal or pathological 
anatomy ; moreover, the theory of the development of most 
of the tissues is the same in pathological as in normal his- 
tology. In order to understand those deviations from the 
normal type which occur in the fcetal condition, pathological 
anatomy demands an accurate previous knowledge of the law 
of development ; indeed there are many points in which these 
two sciences closely approach each other. 

In the establishment of its own observations, pathological 
anatomy requires not merely the theoretical knowledge already 
alluded to, but also the same manual dexterity which is needed 
in the practical exercise of normal anatomy, namely, skill in 
dissection, which can be much more readily acquired by prac- 



INTRODUCTION. 



1 1 



tice than by any verbal, or written instructions. The absence 
of any regularly adopted system of investigation — of that 
savoir faire which diminishes and shortens every difficulty — 
is not so indispensable, but that by application and careful in- 
vestigation it may be retrieved ; and this very savoir faire, 
without such qualities, would only lead to charlatanism, daz- 
zling the eyes of ignorant spectators, but evolving no results 
useful to science. In the investigation of delicate points con- 
nected with pathological histology, the microscope is indispen- 
sable, and the application of chemical re-agents must be 
observed under it. Chemical analysis is, indeed, of the greatest 
importance to pathological anatomy, being the only means by 
which we can on several points obtain the desired information. 
At present, much to the detriment of the science, chemical 
investigation is little pursued in conjunction with pathological 
anatomy; but assuredly the time will soon arrive, when 
chemical analysis will be deemed just as indispensable to the 
prosecution of pathologico-anatomical investigations as the mi- 
croscope is at present, and when every follower of this science 
will consider chemical analysis so essentially requisite, that if 
his own time and opportunities prevent him from carrying it 
out, he will employ a chemist, under his immediate guidance 
and direction, to undertake it for him. 

Pathological anatomy derives the materials of its knowledge 
from two separate sources. First, from observation, which 
includes the examination of portions of the living body altered 
by disease, and removed either by the knife of the surgeon, or 
thrown off as excreta (in the widest sense of the word) together 
with the examination of the dead body, which is often sufficient 
of itself alone to explain to the practised observer the whole 
course of the disease. 

In most cases, it is, however, of importance that the exa- 
mination of the dead body should be supported and perfected 
by observations made during the progress of the disease. It 
is also essentially important to therapeutics, that pathological 
anatomy should be pursued by scientific, unbiassed patholo- 



12 



INTRODUCTION. 



gists, rather than by mere anatomists ; but we must be very 
careful in tracing the connexion which subsists between the 
symptoms observed during life, and the changes noticed after 
death. Hypotheses, which can be as little avoided in patholo- 
gical anatomy as in medicine generally, must be most carefully 
checked, and their actual value borne in mind ; they must not 
be ranked with ascertained facts and theories, if we wish to 
see our science preserve its positive character and its objective 
position high above the troubled flood of medical systems; 
and if we would protect it from the contempt with which cer- 
tain physicians are inclined to regard it. 

The other mode by which pathological anatomy gains 
new facts is by experiment. Experiments instituted on 
animals, and, in certain cases, on man, with the view of arti- 
ficially producing a morbid condition, and then carefully 
studying it, afford most valuable aid ; for here the quality and 
quantity of the causes in action are much more under control 
than in ordinary cases of disease. 

By these means, the actual causes and consequences of indi- 
vidual pathological changes can be much better studied than 
in cases when they arise of themselves, and where their causes 
are frequently either entirely concealed, or can only be followed 
in doubt and obscurity through a multitude of influences, 
whose origin cannot be traced with certainty, or even proba- 
bility. 

We sometimes hear it objected, that from pathological 
changes observed in the lower animals, no certain conclusions 
can be drawn as applicable to man. This objection has, how- 
ever, long been refuted by experience, which shows that, 
bearing in mind the differences necessarily consequent on 
variety of structure, such conclusions are not only admissible, 
but that comparative pathology and pathological anatomy 
afford as much assistance in the prosecution of this 
science in relation to man, as comparative anatomy does 
for the thorough comprehension of human anatomy and 
physiology. 



INTRODUCTION. 



13 



It is, therefore, much to be desired that experiments pro- 
ducing morbid changes in animals should be more frequently 
instituted ; for it is only from a large number of similar 
experiments, not from isolated cases, that conclusions can be 
safely drawn. The adoption of the experimental method in 
pathological anatomy promises farther advantages ; for, by its 
application, the fruitful labours of that science will cease to 
remain the exclusive property of the practical physician, who, 
from his usual occupations, or possibly from his ignorance of the 
means of carrying out microscopic and chemical investigation, 
frequently fails to draw from the cases that come under his 
eye such useful observations as might have profited himself 
and his science. 

The materials thus gained by observation and experiment 
must be used with the greatest care, if science is in reality to 
be advanced by them. This care must, in the first place, 
extend to description ; the object of which is to give to others 
a correct and intuitive conception of the changes that have 
been observed ; hence definite terms must be used, whose in- 
terpretation can admit of no mistake. Care must also be 
taken to describe in like manner all the relations which admit 
of an exact notice, as number, size, and weight. This must 
only be omitted in cases where it is obviously unnecessary, and 
general information will suffice. What these cases are, must 
be left to the judgment of the describer, who must, therefore, 
always clearly understand, in every case that he examines and 
describes, what are the essential points requiring an exact 
description, and what, on the contrary, do not require, or even 
admit of particular notice.^ 

In the next place, it is the object of pathological anatomy to 
examine the various changes occurring in the different parts of 

* On these points the reader may consult with advantage the recent 
Treatise by Engel; Propadeutik der pathologischen Anatomic Wien. 
1845. 



14 



INTRODUCTION. 



the body; to follow each individually through its minutest details; 
and to set forth, as clearly as possible, its causes, gradual develop- 
ment, and consequences. It is only by strictly pursuing this 
course of complete separation and isolation that useful results 
can be obtained, and confusion — that bane of all science — be 
avoided. A comparative examination of the various changes 
shows that there is much in common between many of them, 
and that the same, or similar processes frequently occur in very 
different parts of the body. 

Thus it becomes another department of our science to 
examine into the community of the various changes, and to 
regard them from one general point of view. Hence 
pathological anatomy is naturally separated into a special and 
a general part. Of these the latter, although of the later 
origin in the development of the science, must yet, for the sake 
of a scientific arrangement, be first considered. 

In order to obtain general results in pathological anatomy, 
two different methods may be pursued, similar to those 
already mentioned, in relation to obtaining material for our 
science ; namely, the method of observation and the method 
of experiment. 

Observations instituted on the dead body, teach us what are 
the changes that most commonly occur together ; and from 
the frequency or rarity of their simultaneous occurrence, 
enable us to draw conclusions respecting the relative con- 
nexion of these changes. Experiment seeks to investigate 
the actions induced by artificial causes ; and, consequently, to 
discover the causes and consequences of certain pathological 
conditions in the most direct manner. 

If we wish to attach a scientific value to observations 
grounded on experiment respecting the simultaneous occur- 
rence of certain changes in the human body, and the relation 
in which they stand to each other, such observations must be 
made with the greatest care. Cases imperfectly recorded, 
respecting the frequency or rarity of simultaneous phenomena, 



INTRODUCTION. 



15 



must be rigidly excluded, as unfit to form the basis for any 
sound conclusions. The comparison must be made on an 
exact mathematical basis; and conclusions must only be 
deduced in accordance with the rules of probabilities and the 
laws of high numbers. The numerical or statistical method 
must be carried out as fully as possible. # 

In applying this method to pathological anatomy, we must 
clearly understand what it is actually capable of effecting, and 
neither employ false data, nor overrate the results yielded by 
it. The certainty of its results is dependant on two conditions ; 
Firstly, on the number of the observations ; and, secondly, on 
the accuracy with which each observation is described. 

The more closely these conditions are fulfilled, so much the 
more sure and accurate will be the results yielded. A few 
illustrations will elucidate our meaning. Let us assume that, 
from the Creation to the present time, at least one billion of 
men have lived, and, after a longer or shorter life, have died. 
Of this whole number none have lived beyond a certain age ; 
for instance, no one is now alive who was born in the four- 
teenth century. Hence, the probability that any man now 
alive will die, is to the probability that he will not die, as a 
billion to one. The number is here so large, that no rational 
being can doubt that death must earlier or later ensue. In 
this case, the number of observations is the greatest that can 
possibly occur, and the conditions respecting the nature of the 
observation are clearly defined. Hence, the probability is so 
very great, that it may be deemed an absolute certainty. 

There are likewise other questions respecting which, if the 
numerical method cannot reply with the same degree of cer- 
tainty, it may yet yield an answer for the correctness of which 
there will be the highest degree of probability. For example, 
suppose it be asked what per centage of mankind die before 
their thirtieth year ? Here the object of the question — the 

* Consult Gavarret : Principes Generaux de Statistique Medicale. 
Paris, 1840. 



16 



INTRODUCTION. 



occurrence of death before or after the thirtieth year — may be 
determined with tolerable certainty. In a well ordered coun- 
try, there are few cases in which the age at death is not 
recorded. The official registration of births and deaths places 
a large number of observations at our command ; and from 
these data the question may be answered, not only with 
very considerable accuracy, but we can even approximate 
to the greatest error that can possibly occur in the calcu- 
lation. 

In pathological anatomy the case is, however, different ; for 
the number of observations is much smaller, while the objects 
to be observed are frequently of a very indefinite nature. 
Suppose it were determined to prove, by statistical records, 
that scirrhus and tuberculosis exclude each other. In the 
first place, the meaning of the terms scirrhus and tuberculosis 
must be accurately determined ; for although physicians are 
not likely to dispute whether or not a man is really dead, there 
are few points on which there is more difference of opinion 
than whether a tumour is to be regarded as of a scirrhous 
nature or not. But, even if this difficulty were overcome, 
and it were agreed that a number of observations on the pre- 
sence of scirrhus in undoubted cases were actually made, still 
the number must be comparatively small. Suppose thirty 
cases of scirrhus have occurred without the presence of 
tubercle in any of them ; then the probability that the next 
(thirty-first) case of scirrhus will not be associated with tuber- 
culosis will be as thirty to one. 

But in addition to these cases of scirrhus in which there 
have been found to be no indication of tuberculosis, pro- 
bably 300,000 other cases have occurred, yielding no evi- 
dence for or against its co-existence. Now, if from these 
thirty observed cases, we were to conclude that scirrhus 
always excludes tuberculosis, that is to say, that amongst the 
300,000 cases there had not been a single one in which 
tubercles were present, such a conclusion would, according to 
the laws of probability, be very uncertain, and such an appli- 



INTRODUCTION. 



17 



cation of the calculations, founded on that law, would be mis- 
placed. 

It would be a still more dubious matter to attempt to esta- 
blish, on statistical grounds, not merely the simultaneous occur- 
rence, or non-occurrence of certain morbid changes, but like- 
wise the mutual relations, and the connexion of cause and 
effect existing between them. Suppose it were attempted to 
be proved by statistical records from the dead-house, that 
hydrocephalus in children is the cause of tuberculosis ; or, vice 
versa, that hydrocephalus arises from tuberculosis. Our first 
object would be to obtain statistical information respecting the 
simultaneous occurrence of these two diseases, or of the 
invariable disappearance of the one before the appearance of 
the other ; and the conclusions would be very doubtful unless 
drawn from a large number of cases. It would further have 
to be proved that other morbid changes frequently occurring 
with hydrocephalus, but independent altogether of tuberculosis, 
were not the actual cause ; or, to penetrate still deeper, that 
other changes, invisible in the dead body, may not have pro- 
duced the hydrocephalus. For such reasons as these, the statistical 
information we at present possess, in relation to pathological ana- 
tomy, must be used with the greatest caution. I do not, how- 
ever, desire to underrate the importance of the application of 
the statistical method to our science ; on the contrary, I hold 
it of essential importance that in all serious forms of disease, 
statistical information respecting the morbid changes found in 
the dead body should be carefully drawn up and laid publicly 
before the profession. But these examinations must be made 
with the greatest care ; the nature of the changes must always 
be communicated in the most definite and special manner ; 
and, above all, the observer must avoid drawing general con- 
clusions from too small a number of cases, or from cases badly 
observed and badly described. In our science, we must follow 
the examples set us by the astronomers, magnetists, and 
meteorologists, who continue for years to carry on the most 
careful general observations, and to make them public property, 

vol. i. c 



18 



INTRODUCTION. 



in the hope that the general laws which they fail to establish 
will be developed by their successors. 

The other method by which pathological anatomy can and will 
extend its limits, seeks to penetrate directly into the connec- 
tion of symptoms ; far from excluding the statistical method, it 
is rather an essential completion of it, whilst its results, when 
sure, act as a test for those obtained by the numerical me- 
thod. A few examples will serve to illustrate my meaning. 

Common observation teaches us that venous hyperemia is 
frequently accompanied by a collection of dropsical fluid in the 
surrounding parts. Our knowledge of the functions of the blood- 
vessels renders it probable that the dropsical fluid, in these cases, 
proceeds from the veins, and that their hyperemia is the cause 
of its collection. Carefully instituted experiments, which by 
ligature, or in some other way, have caused venous hyperemia, 
and thus actually produced dropsical effusion, confirm this 
opinion ; and it becomes more sure in proportion to the number 
of experiments, and the different conditions under which they 
were performed, with the view of removing every possible 
source of error. 

The following may serve as another illustration : Experience 
shows us that certain changes in the substance of the kidneys 
are accompanied by the secretion of albuminous urine. A 
close examination of the diseased kidney shows that blood- 
plasma has escaped from the vessels into the substance of that 
organ, and that the fibrin has coagulated there. Physiological 
theory leads us to assume that the fluid portion of the blood- 
plasma becomes mixed with the urine, and that the albumen 
is at least in part obtained from that source. 

In order to fulfil its office, and efficiently to serve general 
and special pathology and therapeutics, pathological anatomy 
must adopt and scrupulously carry out both these methods. 

If pathological anatomy lays claim to the rank of a science, 
it must arrange the results which it has obtained, and exhibit 
them connected in one comprehensive scheme. This can, at 
present, only be effected in a very imperfect manner. One of 



INTRODUCTION. 



19 



the most difficult tasks in the science of pathology, is to classify 
the different diseases, and to arrange them in accordance with 
a scientific system. The great cause of the difficulty consists, 
as we have already mentioned, in their being neither organisms 
nor pseudo-organisms, but merely deviations from the normal 
condition. In pathological anatomy, the difficulty is still greater ; 
for, from its very nature, it must investigate isolated facts ; 
and its general department, if we retain that which is positive, 
and do not adopt too many hypotheses, is at present in a very 
aphoristic condition. Hence, I regard a systematic arrange- 
ment in pathological anatomy — at least at the present time — 
as of small importance, and I shall only add a few words 
regarding the system I have adopted, not so much with the 
view of justifying it, as to assist the reader in the perusal of 
the following pages. 

The special department treats of the pathological changes . 
in different parts of the body. The arrangement is entirely 
arbitrary, and I have adopted it simply with the view of 
avoiding repetition. 

The general part, which proceeds as it were from the 
special, embraces the changes of a more general nature, which 
may occur in different tissues and organs in the same, or in a 
very similar manner, noticing also their general relations, 
causes, and consequences, so far as they are at present known. 
The following sketch of the order in which the different mor- 
bid changes follow each other, will serve as a summary of 
the contents. We commence with abnormal collections of 
fluids in the body — of the gaseous (pneumatoses), of the 
aqueous (dropsies). The latter are divided in a manner that seems 
natural and practically important, although not hitherto adopted : 
namely, into serous, fibrinous, and false dropsies. Then comes 
a sketch of the morbid changes of the blood as far as they 
are at present understood. This is succeeded by a chapter on 
pathological epigeneses, # which from their nature occupy 



* Neubildungen ; literally, new formations. 

c 2 



20 



INTRODUCTION. 



a very considerable space, and by a brief sketch of the 
changes which the tissues undergo in their physical pro- 
perties, together with some remarks on the manner in which 
morbid changes in the elementary tissues are connected with 
each other. The next chapter treats of the independent 
organisms which occur in the human body, as causes or conse- 
quences of morbid changes (parasites). Then there is a 
chapter devoted to congenital pathological changes (malforma- 
tions), and we conclude with a notice of the changes occurring 
in the body after death. 



PATHOLOGICAL ANATOMY. 



CHAPTER I. 

ABNORMAL DEVELOPMENT OF GASEOUS MATTERS.— 
PNEUMATOSES. 

Abnormal collections of gaseous matter are by no means rare, 
either in the living or the dead body. They are included in 
the general term pneumatoses,* and occur in the tissue of 
organs (constituting emphysema), between the fibres of cel- 
lular tissue, as in the parenchyma of the lungs or liver ; and 
in the natural cavities of the body, as in the intestinal canal, 
the peritoneum (constituting tympanites), the pleura (constitut- 
ing pneumothorax), the pericardium, between the membranes 
of the brain, or in the cerebral ventricles ; in the urinary bladder, 
the uterus, the heart, and blood-vessels. f They are most 
common in the intestinal canal, and comparatively rare in the 
other cavities. 

As we shall have occasion to notice most of these pneuma- 
toses in relation to the special organs in which they occur, 

* J. P. Frank, De Cur. Horn. Morb. lib. vi. § 701—730 ; Andral, 
Path. Anat. vol. i. p. 394; Lobstein, Path. Anat. vol. i. p. 134 ; Canstatt, 
Spec. Path. u. Ther. vol. i. p. 178. 

t Otto, Path. Anat. vol. i. p. 42. 



22 



PNEUMATOSES. 



we shall here merely offer a few general remarks on their 
causes and mode of origin. These accumulations of gas 
may be dependant on very different causes. 

1. They may arise from the external pressure of the 
atmospheric air. The mechanism of this form of origin 
is most strikingly seen in those cases of general emphy- 
sema which arise from an injury to the lungs, dependant 
on a penetrating wound of the thorax. If the intercostal 
opening of the wound be not parallel with that in the ex- 
ternal skin, emphysema almost invariably results, since the 
air is forced through the wound at every expiration; and 
instead of escaping externally, is propelled into the cellular 
tissue beneath the skin. If, on the other hand, the external 
opening of the wound is parallel with the internal, and the 
course of the wound is thus kept open, no emphysema results, 
since there is no impedimemt to the progress of the air out- 
wards. The air admitted into the cellular tissue of the 
thorax gradually works its way over the body, and the em- 
physema thus becomes more or less general. The orbits 
become closed up ; the eyes and mouth remain shut, in con- 
sequence of the swollen condition of the eye-lids and lips ; 
the nose is hidden between the tumid cheeks ; the skin of 
the neck is so monstrously distended that all distinction 
between the head and the trunk disappears. The skin is 
most distended at those points where it is connected 
with the sternum and the spinous process of the vertebral 
column. The scrotum swells to such a size as to con- 
ceal the penis. The limbs enlarge and assume a cylin- 
drical form ; the palms of the hands and the soles of 
the feet (in consequence of their firm connexion with 
the subjacent tissues) being the only parts not affected. 
The swollen parts feel tense, crepitate when pressed 
by the fingers, and on removing the pressure no pitting 
is visible. In unfavourable cases, the patient dies from 
impeded respiration and apoplexy, in consequence of the com- 
pression exercised on the air-tubes and jugular veins by the 



PNEUMATOSES. 



23 



swelling. Larrey^ has described two cases of this nature, and 
has given a representation of one of them. Some very simi- 
lar instances are mentioned by P. Frank, after penetrating 
wounds of the larynx or tracheea, and in cases of fractured ribs ; 
and, indeed, without any external lesion in severe cases of 
pertussis and in phthisis; in raising heavy weights, and 
during the pains of labour.f In all these cases there was, 
doubtless, an internal laceration through which the air pene- 
trated from the respiratory organs into the cellular tissue. 
The case is precisely the same in local, or circumscribed em- 
physema; thus, according to Dr. Frank,J persons in the 
habit of playing on wind-instruments, frequently suffer from 
a painful inflation of the cheeks, arising from the air en- 
tering the cellular tissue of these parts, through laceration 
of the buccal mucous membrane. It likewise happens that 
in applying the air- douche, with a view to open and enlarge 
the Eustachian tube in cases of deafness, local emphysema 
is sometimes produced in a similar manner. In this way 
the various forms of pulmonary emphysema are produced, 
of which we shall here only explain briefly the mode of 
origin • since they will be fully discussed when we treat of 
the pathological conditions of the lungs. 

When a portion of lung is so clogged up with fluid or 
solid depositions that no air can enter it, or when it is 
bound down by unyielding false membranes, it is impossi- 
ble that it can follow and correspond with the movements 
of the thorax at each inspiration, as in the normal state. 
A vacuum is formed between the lungs and theparieties of the 
thorax, which the air, entering through the trachsea, endea- 
vours by the ordinary laws of mechanics to fill ; consequently, 
the expansive portions of the lungs are enlarged to a greater 
degree than in the normal state, and the result is vesicular 
emphysema, in which the pulmonary cells of the expansible 

* Larrey, Clinique chirurgicale, tome n. p. 188, planche 4. 
f J. P. Frank, Epitome, cap. vi. § 707. i Op. cit. 



24 



PNEUMATOSES. 



portion of lung become distended, and contain a larger amount 
of air than in a state of health. If, however, in consequence 
of the pressure of the air, or the delicacy in the cell-walls, any 
laceration occurs, the air enters the parenchyma of the lung, 
and interlobular emphysema is the consequence. 

Air may likewise enter the cavities of the body in this mecha- 
nical way, either from the respiratory organs or directly from 
the atmosphere. When vomicae in the lungs, communicating 
with the bronchi, perforate the cavity of the pleura, air is 
forced inwards and pneumothorax is the consequence. 

After wounds of the large superficial veins, especially in the 
vicinity of the heart, where the diastole of the right auricle 
and the enlargement of the thorax during inspiration, exert 
a certain suction-force on the blood, the external air may enter 
the vein and thus be conveyed with the blood to the heart. 

Finally, it appears that many accumulations of gas take 
place mechanically in the course of the intestinal canal (espe- 
cially in the stomach) by the entrance of atmospheric air. 
Pneumatoses of the oesophagus and of the stomach are by 
no means rare, and most commonly occur in hysterical 
and hypochondriacal persons, especially when the stomach 
has been long empty, as two or three hours after meal-time. 
In some of these cases, there is an excess of acid developed in 
the stomach ; in others, on the contrary, there is a deficiency. 
Their most frequent cause is a mental one. # The stomach 
becomes swollen, and forms an elevated, elastic tumour be- 
neath the sternum, yielding a clear sound on percussion. 
Various nervous symptoms, palpitations, dyspnoea, angina, 
pain in the gastric region, &c. accompany the phenomenon, 
which usually disappears with eructations.f Many authors 
(P. Frank, Lobstein, &c.) are of opinion that in these cases 
the gas is secreted by the walls of the stomach. Budge J has, 

* Sir Francis Smith, Dublin Med. Journal. Jan. 1841, p. 454. 

t P.Frank, op.cit. § 714. 

\ Die Lehre vom Erbrechen, 1st Part. 



PNEUMATOSES. 



25 



however, shown that in the eructations which precede vomit- 
ing, and, therefore, probably also in many other cases, atmos- 
pheric air enters the stomach through the oesophagus. I con- 
fess, however, that to me the mechanism by which the air is 
driven into the stomach is not perfectly clear. According to 
Budge, the stomach enlarges its cavity by an active tension, 
and then the air is driven in by the ordinary laws of physics. 
How the stomach can, by a contraction of its muscular fibres, 
dilate itself, and thus produce a vacuum, I do not understand. 
If the fact is placed beyond doubt, some further explanation is 
at least requisite. 

It is possible that some of the cases in which gas is dis- 
charged from the generative organs of the male, from the 
uterus, and the urinary bladder,* may be explained in this 
way : namely, by a mechanical pressure of the air into these 
parts in consequence of a peculiar antiperistaltic motion, or 
dilatation of the organs. In the same manner, in all probability, 
the air passes from the stomach into the other parts of the 
intestinal canal ; however, most of these collections of gas in 
the intestinal canal admit of another explanation, as we shall 
immediately see. 

On making a chemical analysis of these gases, it is 
found that in their composition they are identical with 
common air; but that in consequence, probably, of their 
prolonged contact with the blood and other organised fluids, 
they undergo changes similar to those w T hich occur in the 
lungs in the act of respiration : viz., the oxygen is, in part, 
replaced by carbonic acid, and is saturated with hydrogen. 

2. Gases are developed in the body in consequence 
of decomposition, fermentation, and putrefaction. 

It is well known that most organic matters undergo decom- 
position at the temperature of the human body and in the 
presence of water, even when air is excluded. This decompo- 
sition occurs under the forms of fermentation and putrefaction ; 

— 

* P. Frank, op, cit. p. 724—726. 



26 



PNEUMATOSES. 



and, in many cases, is accompanied with the development of 
gaseous products. That such decompositions, accompanied 
with the development of gas, also occur to the human body, 
and that some pneumatoses are produced in this way cannot 
be doubted by any one who is in the slightest degree 
acquainted with the recent progress of zoo-chemistry. But 
if these general facts are established, our special knowledge of 
the subject is very imperfect ; and it is at present impossible 
to explain theoretically, in any given case, the nature of the 
decomposition, and the properties of the developed gases. The 
following attempt to determine this point with a greater degree 
of certainty must only be regarded as provisional. 

The decompositions of organic matters, which have been 
hitherto studied, have received different names in consequence 
of their different natures. We distinguish : firstly, alcoholic 
fermentation, in which sugar is converted into alcohol and 
free carbonic acid gas. Secondly, acetic fermentation, in which 
alcohol absorbs oxygen, and is converted into acetic acid 
and water, or sugar is converted into lactic acid ; in this case 
no gaseous products are formed. Thirdly, putrefactive fermen- 
tation, which, according to the nature of the putrifying body, 
presents very different modifications, but in which gaseous 
products are usually evolved. The alcoholic fermentation is 
of very rare occurrence in the human body, unless when fer- 
menting drinks, unfermented beer, &c. have been taken 
in large quantities. It appears that in such cases this fermen- 
tation may occur in the stomach, and give rise to the 
development of an accumulation of carbonic acid. Acetic 
fermentation cannot give origin to any pneumatosis, since 
no gaseous products are developed. Hence, there is only 
left the putrefactive fermentation to be carefully studied. As 
a general rule, it occurs very rapidly when portions of vege- 
table or animal organisms are exposed in the presence of 
water to a temperature corresponding with that of the human 
body. The gases that are developed vary in accordance with 
the putrefying substances that give origin to them. Non- 



PNEUMATOSES. 



27 



nitrogenous substances yield carbonic acid, carburetted 
hydrogen, and hydrogen ; nitrogenous matters yield ammonia 
in addition to carbonic acid : if sulphur and phosphorus are 
present, sulphuretted and phosphoretted hydrogen, and 
hydrosulphate of ammonia are also developed. # 

Gas may be developed in this manner in the human body, 
partly from food in the act of decomposition in the intestinal 
canal, and partly from the decomposition of the constituents 
of the body itself. 

a. Development of gas from the decomposition of food 
in the intestinal canal. — Accumulations of gas in the intes- 
tinal canal, at least in its lower portion, and the discharge 
of wind by the anus, are of such common occurrence, that 
they can hardly be regarded as pathological indications. In- 
deed, they occur in perfectly healthy persons. 

That the gas arises from the decomposition of food 
is much more probable than that it is secreted by the 
mucous membrane of the intestines, as the older writers (P. 
Frank and Lobstein) believed. For : firstly, food moistened 
with water, and exposed to a temperature of 95° — 104° for a 
space of twenty-four or thirty-six hours actually becomes 
putrid. Secondly, human faeces present all the signs of putri- 
fying matter; they have a putrid odour, and infusoria are 
developed in them. And, thirdly, the gases in the intestinal 
canal are identical with those which are formed out of the 
human organism during the putrefaction of animal or vege- 
table bodies ; they consist of carbonic acid, hydrogen, carbu- 
retted hydrogen, sulphuretted hydrogen, hydrosulphate of 
ammonia, and nitrogen.f The nitrogen probably arises from 
the air that is swallowed, the corresponding oxygen being 
contained in the carbonic acid. In support of the view that 

* Compare Weinlich, Lehrbuch der theoret. Chemie, p. 344 ; Hiine- 
feld, Chemie und Medicin. vol. i. p. 258 ; Liebig, die organische Chemie 
in ihrer Anw. auf Agrikultur, 1st Edition, p. 200. 

f Compare Berzelius, Thierchemie, 4th Edition, p. 338. 



28 



PNEUMATOSES. 



these gases originate from the food, it may be urged that 
certain species of food give rise to an abundance of gas 
in the intestinal canal, and that sulphur taken medicinally 
gives rise to a copious development of sulphuretted hydrogen,* 
In a state of health, these accumulations of gas in the intes- 
tinal canal are, however, very trifling, or may be altogether 
absent, whilst in certain pathological conditions they are very 
abundant, and may even produce fatal effects. The caecum, 
or colon, will occasionally swell to the thickness of the arm or 
of the thigh, and may even burst.f The explanation of these 
cases is pretty clear on taking a close view of the chemical 
relations of the process of digestion. During healthy digestion, 
as soon as the food has entered the stomach a secretion of 
acid gastric juice is excited, which checks any decomposition 
and evolution of gas. The food, after its conversion into 
chyme, retains its acidity, which is not at once neu- 
tralized by the addition of the bile, but gradually disap- 
pears towards the extremity of the small intestine. Conse- 
quently, in a normal condition, there can be no evolution of 
gas in the small intestine. But nature has further afforded 
means of restraining the decomposition of food in the caecum 
and colon ; for when, after having advanced so far, it still con- 
tains undecomposed sugar, this constituent becomes changed 
into lactic acid, and consequently it happens, according to 
Blondlot,]: that the chyme which has gradually become neutral 
towards the extremity of the small intestine, not unfrequently 
again becomes acid in the caecum. Hence, in the normal 
state, the decomposition of food, accompanied with the deve* 
lopment of gas, is restricted to the lower extremity of the 
intestinal canal. But when, in a diseased condition of the 
digestive organs, the secretion of gastric juice is either entirely 
absent or not sufficiently abundant, the decomposition of the 

* Berzelius, op. cit. 

f P.Frank, op. cit. p. 715— 720. 

X Blondlot, Traite Anal, de la Digestion, § 103. 



PNEUMATOSES. 



29 



food takes places sooner, and a considerable volume of gas 
may be generated. Blondlot has shown, by experiments on 
animals, that the absence, or accumulation of gas is in some 
degree dependant on the nature of the food. When ruminating 
animals take turnips, beans, or peas, which being rich in sugar, 
readily yield lactic acid, there is no development of gas in the 
first stomach. Gas is, however, formed when they have eaten 
hay or clover, which yield no lactic acid, and are, therefore, 
prone to decomposition. m 

The occurrence of these gases is, as a general rule, restricted 
to the intestinal canal, and gives origin to the conditions known 
as meteorism and flatulence. They may, however, find their 
way from the intestinal canal into the cavity of the perito- 
neum, either by an actual lesion, (as in cases of perforation), or 
by permeating the unwounded intestinal walls. That this may 
happen, is obvious from the slate-grey colour of the surface of 
the spleen and liver frequently observed in post-mortem exa- 
minations, and due to the action of sulphuretted hydrogen 
or hydrosulphate of ammonia, which must have permeated the 
walls of the intestinal canal before it could reach those organs. 

Further particulars on this subject will be found in our 
observations on Melanosis. 

b. Development of gas from the decomposition of the 
constituents of the body. — Gas may likewise be developed 
by the putrefaction of the constituents of the animal body, 
either during life or after death. Its occurrence during life 
is not very rare; it takes place in putrid fevers, in 
typhus, and gangrene. Gas is most commonly evolved 
from the animal fluids, especially from the blood, when, 
before undergoing any chemical decomposition, it is 
arrested in different parts of the body, and its purifica- 
tion by respiration and secretion is thus impeded, when 
certain secretions, as the biliary and urinary, are checked, 
and their constituents remain in the blood. Gaseous 



* Blondlot, op. cit. p. 95. 



30 



PNEUMATOSES. 



products are then developed, which collect in the paren- 
chyma of organs, and in the cellular tissue, constituting 
emphysema, and find their way into the cavities, or finally 
are discharged externally. These gases are usually accompa- 
nied by a volatile odorous matter, and consequently evolve a 
penetrating putrid odour. # Morbid fluids effused into the 
cavities of the body may likewise undergo decomposition and 
evolve gases. Thus, pneumothorax may arise from the decom- 
position of fluid effused into the cavity of the pleura, and air 
may collect in the cavity of the peritoneum after gangrenous 
peritonitis. Likewise excretions, as urine or faeces, may develop 
gas when they escape through wounds, lacerations, fistulse, 
&c, into the parts adjacent to their natural passages, and 
there undergo decomposition. 

Many of the accumulations of air arising from putrefaction, 
which are found in the body after death, are formed after the 
cessation of vitality ,f This putrefaction after death takes place, 
however, the more rapidly under similar external conditions 
(temperature of the surrounding medium, and the greater or 
less facility with which the dead body gives off its warmth to 
surrounding objects ; the period that has elapsed between death 
and the examination, &c), in proportion as the constituents 
of the body — at least its fluids — were predisposed towards 
putrefaction during the final period of life. There may, con- 
sequently, be an abundant secretion of gas in the dead body, 
when, from external conditions, it would not have been 
expected, if during life there has been a tendency towards 
decomposition. Hence, in individual cases, it is not always 
easy to determine whether gas found in the body existed 
there during life, or has been developed after death. 

Many cases of pneumatosis in which authors have stated that 
no signs of putrefaction were presented by the body,J belong 

* For further particulars, see Gangrene. 

t See the chapter on the changes of the body after death. 

% Otto, op. cit. p. 42. 



PNEUMATOSES. 



31 



probably to the latter category. Thus the vesicles of air in 
the vessels of the arachnoid, if they actually existed during life, 
and whilst the circulation was still proceeding, would, in 
accordance with the ordinary laws of physics, be conveyed 
with the blood to the heart. 

We have thus shown, that very many of the accumulations 
of air that have been described as occurring in the body, may 
be explained on physical and chemical grounds. There 
remain, however, other cases that do not admit of explanation 
on these grounds, and we are almost led to add, that 

3. Gases may be actually secreted by different parts of the 
body. 

Thus, Magendie and Girardin assert that, on confining a 
portion of the intestine of a live dog between two ligatures, 
in the course of some hours the included portion was found 
full of air, which escaped with a hissing sound on making 
an incision.* In the intestinal canal of swine we sometimes 
meet with considerable accumulations of gas between the 
layers forming the walls of the bowels. Sir Francis Smithf 
has described an interesting case of the development of gas in 
man, which deserves a full notice. He states — " On the 1 2th 
of May, 1840, I was consulted by a gentleman, who told me 
that he often suffered from an enormous development of gas 
in the stomach, which he discharged by eructation : that he 
likewise, occasionally, experienced a development of gas from 
the bladder, and that his skin acted in a similar manner, as he 
had observed in the bath. On the morning of the 15th, 
I found my patient in a bath at 79° F. His breast, 
shoulders, abdomen, and hands, were literally covered with 
minute bubbles of gas. On being questioned, the attendant 
at the bath stated that he had never previously witnessed any 

* Magendie et Girardin, Recherches physiolog. sur les gaz intes- 
tin. Paris, 1824, p. 24. ; Lobstein, Path. Anat. vol. i. p. 138. 
f Dublin Med. Journal, January, 1841, p. 454. 



32 



PNEUMATOSES. 



thing of the kind. On removing the hands and arms from 
the water, the air-bubbles disappeared, but gradually returned 
on again immersing those organs. The bubbles were of the 
size of a pin's head. On wiping them off, they disappeared, 
but gradually formed again." 

In opposition to the above observations of Magendie and 
Girardin, it may be urged that the gas which was developed 
might probably have arisen from the decomposition of rem- 
nants of food in the inclosed portion of intestine, or that the 
portion of gut becoming distended by peristaltic motion, had 
imbibed air from the peritoneal cavity, or from the adjacent 
portions of the intestinal canal ; and, similarly, the escape of 
air from the stomach and urinary bladder, in Smith's case, 
admits of the same mechanical explanation as has been given 
in a previous page. Not so, however, the escape of air from 
the skin : the fact that all bodies, when immersed in water, 
give off a little entangled air, affords no explanation of the 
continuous evolution of gas from the skin : neither does the 
accumulation of air occasionally noticed in the intestinal canal 
of swine seem to admit either of a mechanical or chemical 
solution. If we are asked for the particular causes of these 
developments of gas, I confess I can give no satisfactory reply. 
No secretion of gases occurs in the human body in a normal 
condition ; for the development of gas in respiration is a purely 
physico-chemical proceeding, and is in exact accordance with 
the laws of displacement and diffusion of gases, as has been 
recently proved by Valentin and Brunner ; # and, probably, 
the same law holds good for the development of gas through 
the skin. We can only refer to the analogical proceeding in 
fishes, where we find an actual secretion of gas in the swim- 
ming-bladder, and must, for the present, defer all further 
questions respecting their causes or pathological indications. 



* Valentin, Lehrb. d. Physiolog. d. Menschen, vol. i, p. 559. 



DROPSIES, 



33 



CHAPTER II. 

ABNORMAL COLLECTION OF AQUEOUS FLUIDS. — DROPSIES. 

Morbid collections of aqueous fluids in the body are 
designated by the general terms, hydrops, or dropsy. Drop- 
sies are of very frequent occurrence, and in an anatomico- 
pathological point of view, present many varieties dependant 
on the region of the body in which the fluid has collected, on 
its action on the adjacent parts, and, finally, on the chemical 
properties and mode of origin of the fluid. 

1. The dropsical fluid may be situated in one of the 
serous cavities of the body, and in such cases it often 
amounts to a very considerable quantity. — This class of 
dropsies has been further divided into dropsy of the pleura 
(hydrothorax), dropsy of the pericardium (hydrops pericardii), 
dropsy of the peritoneal sac (hydrops ascites), dropsy of the 
tunica vaginalis testis (hydrocele), dropsy in the cavity of the 
cranium (hydrocephalus), dropsy of the spinal canal (hydro- 
rhachis), and of the eye (hydrophthalmus) . 

In these cases the fluid usually occurs free, and, in accord- 
ance with the laws of gravity, settles in the most dependant 
part of the serous sac. It is, however, occasionally enclosed 
in recently formed membranous sacs. It is then termed 
encysted dropsy (hydrops saccatus). 

2. The fluid may be effused within the parenchyma of 
certain organs. 

This condition is known as oedema ; its ordinary position 
is the cellular tissue beneath the skin, between the muscles, 

VOL. I. D 



34 



DROPSIES. 



&c. The disease is then known as dropsy of the cellular 
tissue (anasarca, hydrops telae cellularis). It is, however, by 
no means rare to find the parenchyma of internal organs 
affected in this manner, as in oedema of the lungs. More- 
over, certain forms of dropsy of the cellular tissue have 
received special names, as oedema of the cellular tissue of the 
upper part of the larynx (oedema glottidis), and oedema of 
the scrotum. 

Some writers* have denied that oedema occurs in internal organs 
of dense texture, as for instance, the liver, spleen, kidneys and brain. 
They are undoubtedly wrong, for collections of dropsical fluids occur in 
these structures, as will be shown when we come to speak of the 
organs specially ; but this condition may be easily overlooked, or ascribed 
to other causes. 

Moreover, dropsical fluids are sometimes found enclosed in 
recently formed membranous sacs, both in the cellular tissue 
and in the parenchyma of organs. These sacs, with their con- 
tents, are termed hydatids. They are closely connected, in 
part, with encysted dropsy, and in part with other formations 
that will be subsequently noticed. 

On examining the properties and chemical characters of 
dropsical fluids, we may divide them into : 

L Serous dropsy, in which the fluid is identical in its 
qualitative chemical composition with the serum of the 
blood. 

2. Fibrinous dropsy, in which the fluid contains dissolved 
fibrin, and in its chemical composition resembles the plasma 
of the blood. 

3. False dropsy (hydrops spurius), in which the fluid 
differs essentially in its chemical composition from either of 
the preceding forms. 

These three forms of dropsy differ, not merely in the 
physical and chemical characters of their fluids, but likewise 
very essentially in their causes. 



* Lobstein, op. cit. vol. i. p. 156. 



DROPSIES. 



35 



Dropsical fluids are not always pure ; they frequently con- 
tain extraneous substances, as, blood, pus, ichor, &c. 

We shall not in this place enter fully into the various points connected 
with these fluids. The various forms of dropsy occurring in different 
parts of the body, will be fully discussed in the chapters on the indivi- 
dual organs. Here we shall merely treat of their general relations, and 
the causes of their formation ; in this point of view, the chemical 
arrangement is the most suitable. The above chemical differences 
in dropsical fluids have only very recently been accurately determined, 

I. SEROUS DROPSY. 

Dropsy in which the effused fluid corresponds with the 
serum of the blood is by far the most common, and consti- 
tutes true dropsy in the restricted sense of the word. Most 
cases of ascites, hydrothorax, hydrocele, anasarca, and 
cedema, belong to this category, as likewise do the fluids of 
pemphigus, blisters, &c. 

Properties and chemical composition of the fluids occur- 
ring in serous dropsy. — It is only the dropsical fluids effused 
in serous cavities, or enclosed in cysts, that can be collected 
in large quantity and in a state of purity, and be submitted 
to analysis ; although the fluid of cedema does not admit of 
being collected in so large a quantity, or in the same degree 
of purity, it cannot be doubted that in its chemical and phy- 
sical properties it is perfectly similar. 

A pure dropsical fluid is generally nearly clear, limpid, or 
colourless ; or, it may be, of a yellowish green tint, more or 
less turbid, opalescent, and whey-like. 

Its reaction is most commonly alkaline, rarely neutral, and 
still more rarely acid. Sometimes it is as fluid as water, but 
is frequently thick, viscid and tenacious. 

Under the microscope it appears as a pure fluid ; it fre- 
quently, however, contains a small amount of corpuscles 
which, on standing, form a more or less abundant sediment. 
This sediment may possess various properties, and be depen- 
dant on very different modes of origin. It may contain 

d 2 



36 



DROPSIES. 



fragments of epithelium from the serous surface, accidentally 
mixed with the fluid, pus-corpuscles from secondary suppu- 
ration, blood-corpuscles accidentally present, or finally, but 
rarely, an actual deposition of inorganic matter. The fluid 
of hydrocele frequently contains a crystalline deposit of 
cholesterin. 

The many differences observed in the physical properties of drop- 
sical fluids are dependant, for the most part, on the presence of extra- 
neous matter. In a perfectly pure condition, the fluid of dropsy is 
either colourless, or of a yellow or yellowish green tint from the 
presence of bile-pigment. On the addition of nitric acid, it then yields 
the series of colours indicative of bile-pigment ; that is to say, a little 
nitric acid renders it green ; on the addition of more acid, it becomes 
blue, then violet- coloured, a hyacynthine tint, and finally of a pale 
yellowish red colour. A red colour is dependant on hsematin ; a milk- 
white turbidity, on the admixture of fat or epithelium scales, or of 
albumen, if the fluid is very aqueous.* The consistence varies with the 
chemical composition ; the more water is present, the thinner it is. A 
large quantity of albumen renders it viscid ; a very large quantity (above 
12%) renders it thick, tenacious, and capable of being drawn out in 
threads, like albumen itself. Its alkaline reaction appears to be due, 
like that of the blood, to alkaline carbonates (?) or basic phosphates. 
An acid reaction is rare, but sometimes occurs in dropsy after miliary 
fever and acute rheumatism : the acid on which the reaction is 
dependant is probably lactic acid. I have on several occasions attempted 
to isolate it, but always without success, in consequence of the small 
quantity present. 

The chemical constituents of the dropsical fluid are identical 
with those of the serum of the blood; water, organic substances, 
especially dissolved albumen, fat, and extractive matters, 
(sometimes, also, small quantities of urea, bile-pigment, and 
haematin) and various salts, (chiefly alkaline and earthy carbo- 
nates, (?) and phosphates, and chlorides.) The amount of these 
constituents is somewhat variable ; sometimes the dropsical 
fluid is identical in its quantitative composition with the serum 
of the blood ; but, most commonly, there is more water and 

* Scherer, Untersuch. p. 113; or Simon's Animal Chemistry, Lon- 
don, 1846, vol. ii. p. 491. 



DROPSIES. 



37 



less organic matter to the same amount of salts. It is only- 
very rarely that we find it more concentrated, and richer in 
organic constituents than the serum. 

Dropsical fluids, especially those that have collected in large quantity 
in the serous cavities, have been often submitted to analysis. Of these 
analyses, I will only quote so many as are essential to the clear under- 
standing of their chemical relations,* and for their better comparison 
with the normal serum of the blood. 

12 3 4 

Serum of the Hydrocele. Hydrocele. Ascites, 
blood. 

Water 905.0 920.0 927 946 

Albumen 78.01 48 33 
Extractive > 71.5 

matter 4.2 J 10 \ 

Fat 3.8 9 J 

Salts 9.0 8.5 6 



13 



1000.0 999.0 1000 1000 



5 


6 


7 


Ascites. 


Ascites. 


Ascites. 


956 


988.0 


704 


29 


0.9 


290 


9 




2 


1} 


10.0 


4 


1009 


998.9 


1000 



1 . Healthy serum of the blood, the mean of two analyses by Lecanu, 
(Etud. Chim. sur le Sang, p. 57). 

2. By Marcet, (Leop. Gmelin, vol. n. 2nd Part, p. 1392. 

3. By v. Bibra, (Chem. Untersuch. versch, Eiterarten, p. 160.) 

4. Analysed by myself. 

5. By v. Bibra, (op. cit. p. 170.) 

6. Analysed by myself ; the fluid was turbid and of a milky appear- 
ance. 

1.. By Dublanc (Leop. Gmelin, vol. n. 2nd Part, p. 1391.) 

These analyses, conducted in different ways, and therefore not admit- 
ting of close comparison, clearly show the great similarity between the 
serum of the blood and these dropsical fluids. In analysis 2, the drop- 
sical fluid is almost identical quantitatively with the serum ; in the 

* The most important chemical analyses of dropsical fluids may be 
found in the following works and Memoirs : — Berzelius' Thierchemie, 
4th Edit. p. 198 ; Leop. Gmelin's Chemie, vol. n. 2nd Part, p. 1388, 
&c. ; D. Wagner, mediz. Jahrbuch d. osterr. Staates, 1833, vol. v. 
p. 2 ; Marchand and Bouchardat, in Valentin's Repert. vol. n. p. 198 ; 
Babington and Becker, in Valentin's Repert. vol. v. p. 359 ; Marquart 
in Albers' Atlas d. path. Anat. 14th Part; Valentin's Repert. vol. vi. 
p. 300; v. Bibra, chem. Untersuch. verschied. Eiterarten, Berlin, 1842, 
p. 155, &c. ; Scherer, chem. u. mikrosk. Unters. z. Pathologie, p. 112* 
119, 125 ; Simon's Animal Chemistry, vol. n. p. 490, &c. 



38 



DROPSIES. 



following analyses, the amount of water increases, and of albumen 
diminishes, till in analysis 6, the latter has reached its minimum. The 
amount of salts, on the other hand, remains very nearly the same. The fat 
and extractive matters are extremely variable, and we cannot very well 
compare them in the two fluids. Analysis 7 shows that dropsical fluids 
may be more concentrated than the serum of the blood ; and it would 
not be difficult to refer to other cases illustrative of the same point ; for 
instance, several are given byScherer;* they are, however, comparatively 
rare, and only occur when the effusion is of some standing, and a portion 
of the water has been gradually removed by absorption. In most of 
these cases, where the fluid is very thick and pultaceous, peculiar terms 
are applied, as, for instance, cysts, hygromata, &c. The causes of these 
varieties are, for the most part, enveloped in mystery ; we shall, however, 
notice them in our observations on the causes of dropsy generally. 

If, in its general characters, the dropsical fluid resembles pure or 
diluted serum, there still may exist in many cases chemical differences 
between them, which can only be detected by a careful analysis. The 
essential organic constituent of the serum, as likewise of dropsical fluids, 
is dissolved albumen, which, in the majority of cases, has all the proper- 
ties of pure albumen or of albuminate of soda : it either coagulates 
immediately on the application of heat, or in the latter case, after the 
albuminate of soda, has been decomposed by an acid. On submitting 
this albumen to ultimate analysis, it is found to be identical with the 
ordinary protein- compounds (Scherer).f Sometimes the fluid does not 
coagulate thoroughly on boiling, even after the previous addition of an 
acid, although a large quantity of albuminous matter is present : the 
albumen appears, therefore, to be modified ; it separates on evaporation 
in the form of a membrane, and in that respect, although not in its 
behaviour towards reagents, it resembles casein ; this was observed in 
some of the cases analysed by myself. Scherer found a substance of 
this nature, similar in many respects to mucus, in the fluid of ovarian 
dropsy, which likewise contained albumen and albuminate of soda. 
Elementary analysis proved that in its composition, it differed from 
protein (2Pr + NH 3 — 0 4 )4 Moreover, Collard de Martigny found, in 
the contents of a long standing cystic tumor between the uterus and 
rectum an albuminoid matter, differing however from actual albu- 
men :§ but it appears to be questionable whether the case should be 

* Chem. und mikr. Unters. p. 125, 130. 
f v. Bibra, op. cit. p. 217. 

X Scherer, op. cit. p. 129; or Simon's Animal Chemistry, vol. u. 
p. 487. 

§ L. Gmelin, op. cit. vol. n. 2nd Part, p. 1393; or Simon's Animal 
Chemistry, vol. n. p. 485. 



DROPSIES. 



39 



regarded as one of dropsy. In many cases a portion of the protein- 
compounds is thrown down by the mere addition of water, but on 
adding a neutral salt, the precipitate dissolves, as is frequently ob- 
served in the albumen of the egg. From these observations, it follows 
that the protein- compounds occurring in dropsical fluids, present various 
chemical modifications — modifications which, in the present deficient state 
of our knowledge regarding the protein- compounds, it is impossible 
clearly to elucidat3. Urea has been frequently noticed in dropsical fluids; 
thus in three cases, Marchand found 4.2, 6.8 and 5 in 1000 parts of 
fluid.* In other cases, again, this substance is either entirely absent, 
or is present in so very small an amount as to render its quantitative 
determination impossible (Scherer'sf and my own observations). The 
salts in dropsical fluids are in general the same as occur in the serum 
of the blood. Chloride of sodium is usually the predominating ingre- 
dient ; the other salts — phosphate and carbonate (?) of soda, sulphate of 
potash, phosphates of lime and magnesia, and lactates — occur in smaller 
and very variable quantities^. 

Under the term dropsical fluids, we include some which, 
from their pathology, are distinguished by special names ; but 
which in respect to their chemical composition, as likewise 
to their mode of origin, are identical with the fluids we have 
been considering. These are the fluids of the bullous exan- 
themata (erysipelas bullosum, pemphigus, pompholyx), the 
vesicles resulting from burns, or from the application of 
cantharides, and those occurring in gangrene. The for- 
mation of bullse differs in this respect alone from true 
dropsy, that the fluid is not enclosed within a shut sac, or 
effused in the tissue of an organ, but is confined beneath the 
cuticle, which is thus elevated, so as to constitute a blister. 
Some of these fluids form, as it were, the transition from 
serous to fibrinous dropsy. Moreover, dropsical fluids may 
be mixed with the secretions ; for instance, with the urine, 
which, in such cases, is albuminous ; with the sputa in oedema 
of the lungs, &c. 

* Valentin's Repert. vol. u. p. 198, and vol. in. p. 212. 

f Op. cit. p. 116; or Simon's Animal Chemistry, vol. n. p. 49 L 

* Compare v. Bibra, op. cit. p. 159, &c. ; Scherer, op. cit. p. 121, 
124; or Simon, op. cit. vol. n. p. 490, &c, 



40 



DROPSIES. 



Some of these fluids have not yet been fully analysed. The fluid in 
blisters produced by burns, or the ordinary vesicants, (independently of 
minute flocculi, consisting of coagulated fibrin, pus-corpuscles, and 
epithelium-cells,) is clear, and sometimes of a yellowish- green colour, 
communicates a blue tint to reddened litmus paper, and in addition to its 
principal constituent albumen, contains a little fat, extractive matters, and 
the ordinary salts of the serum of the blood. In the fluid from a blister 
raised by cantharides, which on heating coagulated into a solid mass, 
Bostock found: water 928.6; albumen 60; extractive matters 1.4; 
salts 10.* The fluid of the vesicles that are found on the body, in cases 
of gangrene, is red (from dissolved hsematin), but clear, resembling port 
wine diluted with water, and contains so large an amount of albumen, 
that on boiling it coagulates into a firm mass. The fluid of sudamina, 
containing no albumen, is not included in this category. 

Causes and mode of origin of serous dropsy. — The close 
coincidence between the chemical composition of the fluid of 
dropsy, and the serum of the blood, seems to suggest that the 
former takes its source from the latter. Pathologico-anato- 
mical observations and experiments on animals confirm this 
view ; showing that any impediment to the venous circula- 
tion, in whatever part of the body it may occur, is accom- 
panied by an effusion of dropsical fluid from the veins 
affected into the adjacent parts. Here we are induced 
to believe that serous dropsy always proceeds from the 
venous system, and that it takes place as soon as there is a 
want of balance between the porosity of the venous walls 
and the specific gravity of the blood contained therein ; that 
is to say, when the venous walls become more porous, or the 
blood lighter and more aqueous than in the normal condi- 
tion. In either case there is an increased transudation of 
serum through the walls of the vessels.f This is the manner 
in which local dropsy invariably occurs where individual 
veins are compressed, or, either for a time or permanently 
obstructed, as in cases of pressure from a tumour, or of com- 
plete obliteration. In this manner, the pressure of the impreg- 
nated uterus causes oedema of the feet ; and pressure on the 

* Leop. Gmelin, op. cit. vol. n. 2nd. Part, p 9 1394. 

t Compare Henle in Hufeland's Journal, May, 1840, p. 13. 



DROPSIES. 



41 



vena porta? and vena cava ascendens, arising from degenera- 
tion of the liver, or some other tumour, produce ascites and 
oedema of the lower part of the body. 

Instances of this nature are so numerous, and occur so frequently to 
every observant physician, that it is unnecessary to refer to special exam- 
ples. In all these cases, if there are no anastomoses to carry off the 
venous blood, the hydrostatic pressure of the blood in the affected veins 
increases, and their walls become distended and attenuated. An 
increased flow of arterial blood to a particular part produces a similar 
result. If the aorta of an animal is compressed or tied below the spot at 
which the renal arteries are given off, dropsical effusion takes place from 
the renal veins ; for the veins, as the most yielding part of the vascular 
system, become first distended by the increased quantity of blood.* 

From these experiments we are led to the belief that the blood, under 
the influence of strong pressure, causes and gives origin to the forma- 
tion of dropsical fluids, by permeating the attenuated vein- walls, so that 
the whole proceeding might at first sight be regarded as purely mechanical. 
This, however, is not the case, and the phenomena still present much 
that is obscure. In the first place, it is remarkable why the fibrin 
dissolved in the plasma does not enter into the dropsical fluid ; and 
secondly, why, as a general rule, dropsical fluids should contain as large 
an amount of salts, and more water, but less albumen than the serum 
of the blood. This shows that the process is more complicated than 
at first sight it appears to be. A more accurate acquaintance with the 
relations of endosmosis than we at present possess is required to explain 
these points in a satisfactory manner. 

As a local action on individual veins gives rise to local 
dropsy, so general dropsy is produced by causes acting on the 
venous system collectively ; such as organic diseases of the 
heart and lungs, which hinder the return of the venous blood 
to the right side of the heart, and consequently give rise to an 
increased hydrostatic pressure throughout the whole venous 
system. 

We shall enter at length into this subject, when treating of the patho- 
logical anatomy of the lungs and heart. 

Dilatation of the veins, and subsequent dropsy may be 

* Compare the investigations of Meyer in Roser und Wunderlich's 
Archiv. fiir Physiolog. Heilk. 1844, Part 1, p. 119; and those of 
G. Robinson in the Medico- Chirurg. Trans. 1843, p. 51 — 79. 



42 



DROPSIES. 



dependant not merely on external causes acting mecha- 
nically on those vessels, but may arise from dynamic 
causes, such as nervous influence alone. In this way, 
dropsy occurs in paralysed limbs in very debilitated consti- 
tutions. # Under this head we may also place (what is 
termed) inflammatory dropsy, which is either a complication 
of dropsy with inflammatory exudation, or mere dropsy 
caused by an esoteric dilatation of the veins dependant on the 
nervous system, and accompanied by symptoms of irritation, 
(Fuchs's hydrochysis) . 

Dropsies of this sort are very frequent, but the phenomena accom- 
panying them are generally complicated, and consequently their causes 
are not so immediately obvious as when the dropsy is dependant on 
mere mechanical conditions. To this class belong the blisters arising 
from burns or ordinary vesicants, erysipelas bullosum, anasarca after 
scarlatina and acute rheumatism, inflammatory hydrothorax, and acute 
hydrocephalus. These subjects, however, fall under the head of the 
pathology of the nerves, rather than of pathological anatomy. The 
difference between dropsy and inflammation will be found in our next 
section — on fibrinous dropsy. Serous dropsy, in my opinion, appertains 
to the venous system; and fibrinous dropsy to the capillary vessels. 

The forms of dropsy already considered, take their origin 
in an attenuation (and increased porosity) of the venous 
walls ; another cause of dropsy is probably to be sought 
for in an attenuation of the blood. Even at a very early 
period, the causes of most dropsies were referred to a modi- 
fied condition of the blood, including those which we now 
know to arise from distention of the venous walls. Recent 
experiments have, at least, in isolated cases, confirmed this 
view ; thus, Magendie found that dropsical effusions occurred 
after defibrination of the blood, and the same has been 
observed by Valentin, myself, and others, after the injection 
of a large quantity of water into the vessels. (In rabbits 
dropsy was easily induced ; in dogs with more difficulty). 
Moreover, dropsy occurs when the blood has been rendered 

* Compare Henle in Hufeland's Journal. 



DROPSIES. 



43 



very aqueous by repeated venesection. Moreover, it is pro- 
bable that the retention of the aqueous secretions, (as in 
cases of suppression of the cutaneous perspiration and urine,) 
may give rise to an excess of water in the blood, and thus 
cause dropsy. # 

Our knowledge on these points is, however, still very imperfect. A 
large number of quantitative analyses of the blood in cases of dropsy 
may serve to fill up some of these deficiencies. It is not every temporary 
overloading of the blood with water that causes dropsy, otherwise 
the abundant use of water, if not at once carried off by the kidneys, 
would always produce it ; hence other relations, at present unknown to 
us, are in action. 

Henle's explanation of the causes of dropsy have obtained for him a 
deservedly high reputation. The laws which he has laid down appear 
to me only in so far to require limitation, that instead of referring the 
source of dropsical fluids to the vascular system generally, it should 
be limited, as we have already stated, to the venous system alone. 

Further progress of the dropsical fluid after its effusion. 
A dropsical fluid may be either resorbed or remain un- 
changed. As only the aqueous portion admits of resorption, 
the fluid may become thickened. It admits of no organi- 
zation, and cannot act as a cytoblastema for organic for- 
mations. 

Whether, and to what degree dropsical fluids become resorbed 
depends on various causes. The veins resorb the aqueous portion by 
endosmosis, with a facility proportionate to the tenuity and dilution of 
the fluid. Hence it is clear that venous resorption cannot occur when 
dropsy is dependant on a mechanical impediment to the venous circula- 
tion. It takes place, however, when dropsy arises from a dynamic 
dilatation of the veins, as soon as there is a remission of the noxious 
agency. In addition to the veins, the lymphatics, also, exert a power of 
resorption ; and if for any reason, the functions of both classes of ves- 
sels are destroyed, there can obviously be no resorption. On the other 
hand, resorption by the lymphatics may proceed with such activity that 
the effused fluid is at once removed ; and, therefore, cannot collect in any 
quantity. In this point of view, the old opinion, that dropsy was 
dependant on increased exhalation and diminished resorption, has a 
certain degree of truth. Resorption is, however, dependant on local 



* Henle, op. cit. p. 16, 



44 



DROPSIES. 



relations and circumstances. CEdema, in portions of the body abun- 
dantly supplied with lymphatics, disappears much more readily than 
dropsy in cavities where the only absorbents are situated on the surface. 
By the absorption of the water and salts, in accordance with the laws 
of endosmosis, the fluid becomes thicker, and ultimately forms a viscid 
mass, containing comparatively little water, but much albumen (see 
p. 37, anal. 7). That the dropsical fluid never forms a cytoblastema 
in which pus-corpuscles or other cells can be developed, I have con- 
vinced myself by numerous experiments. When pus- corpuscles and 
other organic forms occur in dropsical fluids, they always arise from 
other plastic processes accidentally combined with the dropsy. But by 
chemical influences some of its own constituents may be separated, as, 
for instance, cholesterin, or albumen, on diluting the fluid with water 
(see page 39). 

Diagnosis of the dropsical fluid, and its anatomical 
relations. — Dropsical fluids may be recognised by the phy- 
sical and chemical characters already described. They are 
distinguishable from the spurious dropsical fluids (subsequent- 
ly to be described), by their containing fluid albumen, which 
coagulates on the application of heat, or the addition of nitric 
acid. A precipitate is caused by the addition of nitric acid, 
when (as we have already mentioned), the albumen is modi- 
fied, and no longer coagulates on boiling. It is only in 
those cases in which the dropsical fluid contains so little 
albumen that no coagulation occurs, either on boiling, or 
on the addition of nitric acid, that the diagnosis becomes 
difficult or doubtful ; then, however, a quantitative analysis 
usually gives the required information. It is distinguished by 
negative characters from other morbid fluids, as fibrinous 
dropsy, pus, &c. ; it does not coagulate spontaneously, and 
contains no essential corpuscles, such as occur in blood and 
pus. By means of a quantitative analysis we can sometimes, 
but not generally, ascertain whether these substances are 
mingled with the dropsical fluids. 

On this subject, see the remarks on the following fluids. 

If the dropsical fluid is contained in a serous cavity, the 
sac becomes distended, and compresses the adjacent organs. 



DROPSIES. 



45 



The serous membranes enclosing the fluid are usually (and 
always when the disease is of any duration) loosened 
(aufgelockert), pale, dull, and opaque. In cavities with yielding 
walls, fluctuation may be detected by percussion. 

In infiltration of the tissues, there is a soft, pasty, shining 
tumidity, which pits on pressure of the finger. On making 
a puncture or incision, the fluid escapes either by drops, or 
in a stream, in proportion to the quantity present. The 
fluid occurs in the first place in the interstices between the 
elementary parts of the tissues, which imbibe it and assume 
a less compact and more flaccid appearance than in the 
normal condition In recent cases, that is to say, when the 
venous dilatation that has caused the dropsy has only occurred 
shortly before death, the dropsical organs appear to be 
reddened (as is frequently noticed in pulmonary oedema) ; 
usually, however, they are pale, and only the larger veins 
appear to contain much blood. 

More on this subject will be found in the second part when 
speaking of the separate organs. 

2. FIBRINOUS DROPSY. 

This species of dropsy, distinguished by the circumstance 
of the effusion containing dissolved fibrin, is not rare, being 
of more frequent occurrence than the preceding, although 
hitherto it has seldom been described, # and its signification 
has not been properly interpreted. It has never hitherto been 
correctly distinguished from serous dropsy, and has conse- 
quently never had a special name assigned to it. Like serous 
dropsy, it may occur either in serous cavities (as in the pleura, 

* Cases in which this form is described are given by : Schwann and 
Magnus, in Miiller's Archiv. 1838, p. 95, &c. ; Delaharpe, in Archives 
gener. de Med. Juin, 1842 ; Scherer, Unters. z. Patholog. p. 106 — 110; 
or Simon, op. cit. v. n. p. 491, &c. ; Gluge, Anat. mik. Unters. 
1838, p. 74; Quevenne, Journal de Pharmacie, Nov. 1837. I have 
myself observed a very large number. 



46 



DROPSIES. 



arachnoid, peritoneum, or pericardium), or may collect in the 
parenchyma of organs, either by infiltration, or by filling recent- 
ly formed cavities in them, as, for instance, in the substance of 
the brain. Hitherto, this occurrence has received the general 
name of dropsy ; effused into the peritoneum, it is known as 
ascites; into the pleura, as hydrothorax or empyema; into the 
parenchyma of organs, as oedema. This morbid process is, 
however, distinguishable by the circumstance, that the fluid 
does not, like that of serous dropsy, present any constancy in 
its behaviour towards different reagents, but under varying 
circumstances occurs in varying forms, as will be fully shown 
in its proper place. 

Properties and chemical composition of this fluid. — The 
fluid is essentially the same, whether obtained from the 
parenchyma of an organ, or from a serous cavity. In the 
latter case, however, it may be obtained in larger quantity, 
and purer, and consequently its different properties are more 
obvious. 

Examined immediately on its discharge, the fluid resembles 
in all points that of serous dropsy. It is either perfectly 
clear and colourless, or else more or less turbid, opalescent, 
and of a greenish yellow colour ; and, examined microscopi- 
cally in its recent condition, exhibits either no solid particles, 
or only such as may be accidentally present, as occasionally 
minute amorphous coagula of fibrin, pus-corpuscles, &c. 
Some time after its discharge, the whole fluid generally coagu- 
lates in consequence of holding fibrin in solution, and forms 
a homogeneous, tremulous jelly, which, after standing for 
some time, separates into a partially consistent, colourless, or 
yellowish-red clot of coagulated fibrin, and a clear, yellow 
fluid analogous to the serum of the blood. On washing the 
clot with water, and pressing it between folds of fine linen, 
we obtain a small quantity of tolerably firm, stringy fibrin, 
precisely similar to that which may be obtained from fresh 
blood by stirring and thoroughly washing. 



DROPSIES. 



47 



The coagulation of the fibrin sometimes takes place in the body 
during life, as we shall presently show. The coagulation out of the 
body, to which we have already referred, varies considerably in the time 
of its occurrence ; sometimes taking place in an hour, in other cases, 
not until the lapse of twelve, or even twenty-four hours. Moreover, 
Delaharpe (op. cit.) has occasionally observed the fibrinous clot re-dis- 
solve in the fluid. The coagulated fibrin appears under the microscope 
as a perfectly amorphous mass, and devoid of any traces of cellular 
structure. 

In its chemical composition, this fluid is identical with the 
plasma of the blood ; that is to say, with the blood indepen- 
dently of its corpuscles ; it is serum, or the fluid of serous 
dropsy, with dissolved fibrin. By chemical analysis, we find 
that it contains : water, dissolved fibrin and albumen, fat, 
extractive matters, and salts (chloride of sodium, carbonate 
(?) and phosphate of soda, sulphate of potash, phosphates of 
lime and magnesia, carbonate (?) of lime, and lactates). 
The similarity of the fluid to the plasma of the blood 
occasionally extends even to their quantitative composition; 
usually, however, the dropsical fluid is the richer in water, 
and contains a less amount of organic constituents — albumen 
and fibrin. It is very seldom that this rule is reversed. In 
this point, therefore, there is the same relation as between the 
fluid of serous dropsy and the serum of the blood. 

In order to give a clear view of these relations, I shall communicate a 
few analyses, preceded by a formula representing the mean composition 
of the plasma of the blood. 

1000 parts of fluid contain : 

1 2 3 4 5 

Plasma of Empyema. Empyema. Empyema. Ascites. 

the blood. , * , , ^ 

a. b. c. A. B. 

)06 903,5 945,6 953 941 935,5 936 881 

3,4 1,7 1,09 0,91 — 0,62 0,60 83 

77 77,5 47,3 32 42,2 49,8 52,8 27 

11 rr l . } • } U |f w 1 9 

8 J J 8 8,1 8 7,4 J 



Water 
Fibrin 

Albumen . . 
Extractive matters 
Fats 
Salts 



1000,4 999,7 1000,0 1000 998,5 999,4 999,8 1000 

1. The mean composition of the plasma of the blood, according to 
Lecanu. 



48 



DROPSIES. 



2. The fluid of empyema removed by paracentesis, analysed by 
Quevenne.* 

3. The fluid of empyema consequent on pleuritis, analysed after 
paracentesis by Dr. Merklein and myself. 

a. Discharged at the first operation, on the 18th of January, 
1841. 

b. Discharged at the second operation, on the 25th of January. 
On both these occasions the fluid coagulated after some 
hours. 

c. Discharged at the third operation, on the 27th of January, 
shortly before the patient's death. It did not coagulate, and 
contained no fibrin ; that constituent seemed to be supplanted by 
pus-corpuscles, which formed a white, creamy sediment at the 
bottom of the fluid. 

4. Fluid of empyema, analysed by Scherer.f 

a. The fluid yielded at the first operation. 

b. The fluid yielded at the second operation, eight days sub- 
sequently. 

5. Fluid of ascites, analysed by Schwann. J The form of the analysis 
is slightly modified, in order that it may admit of comparison with 
those that precede it. The amount of fibrin is so large, that a doubt 
arises whether the amount stated was actual fibrin. 

These analyses are sufficient to show the close similarity, in a quanti- 
tative point of view, that exists between the fibrinous form of dropsy and 
the plasma of the blood. The differences are slighter than between serous 
dropsy and the serum of the blood. Analyses 3. and 4. are especially inte- 
resting, as showing that there may be very considerable differences in the 
secretion of the same organ of the same individual under similar 
circumstances. It seems impossible to make analysis 5. (by Schwann) 
harmonize with the others ; probably the amount of fibrin is much 
overstated. It is very possible that Schwann neglected to wash the 
clot before drying it, and that it contained pus- corpuscles, &c. At 
any rate, this seems to be the case when we consider that the amount 
of fibrin in the dropsical fluid (according to this analysis), exceeds 
by twenty-four times the amount in the normal plasma. With 
respect to the other constituents of fibrinous dropsy, the same observa- 
tions apply as to serous dropsy. The albumen occurs either as pure 
albumen, or albuminate of soda. Of the fixed salts, Scherer§ found 
chloride of sodium 7.5, carbonate of soda 0.8, phosphate of soda 0.4, 
sulphate of potash 0.9, phosphate of lime 0.3, carbonate of lime 0.3 ; 
total 10.2 in 1000 parts of fluid. 



* Journal de Pharmacie, Nov. 1837. t Op. cit. p. 106. 

t Miiller's Archiv., 1838, p. 95. § Op. cit., p. 111. 



DROPSIES. 



49 



In analysis 3 b instituted by Dr. Merklein and myself, the salts in 
1000 parts of fluid amounted to 8, of which 0.4 was phosphate of lime ; 
there was also much carbonic and a little sulphuric acid, chlorine, and a 
trace of phosphoric acid ; of bases there was much soda, and traces of 
potash, magnesia and lime. In 3 a there was much chlorine, a little 
phosphoric acid, much carbonic and no sulphuric acid. 

The fluid of fibrinous dropsy may be effused on the sur- 
face of the body in vesicles and pustules, in the same manner 
as the fluid of serous dropsy : it always occurs in the pustules 
of variola and varicella, at least in the early stages ; fre- 
quently in the blisters from the ordinary vesicants, and burns 
before they have proceeded to suppuration, and in many other 
similar cases. It may also be mixed with the secretions, in 
which case they possess the property of spontaneous coagu- 
lation ; this has sometimes been observed in the urine. # 

I may mention, as a case of this sort, a secretion containing 
dissolved fibrin, from the udder of a goat : it is interesting as 
showing that the same process takes place in animals. In the summer 
of 1842, I received from a veterinary surgeon a glass with the following 
note. " It contains a fluid from the udder of a goat suffering from inflam- 
mation of that organ, it is originally of a pale green colour, and issues 
only from one teat, the others yielding normal milk." The fluid 
amounted to about an ounce, was of a greenish yellow colour, and rather 
turbid. There was floating on it a coagulum somewhat larger than a 
walnut, which did not make its appearance till after it had been 
despatched to me. It was larger than the orifice of the glass, so that 
there was some trouble in removing it. The fluid appeared homogeneous ; 
but when examined under the microscope was seen to contain innumerable 
normal pus-corpuscles about the 400th of a line in diameter, which 
gave rise to its turbidity. The clot was composed of coagulated fibrin, 
which, when examined under the microscope, appeared to be amorphous ; 
it enclosed numerous pus -corpuscles, and a section exhibited a radiating 
appearance. Not a trace of milk-globules could be seen either in the 
fluid or in the coagulum. 

Causes, mode of origin, and further development of 
fibrinous dropsy. — If there are good reasons for believing 

* Compare H. Nasse, Unters. z. Physiolog. und Pathol. 2nd Part, 
p. 209. 

VOL. I, E 



50 



DROPSIES. 



that the fluid of serous dropsy is derived from the blood, the 
reasons in favour of the fibrinous fluid arising from the same 
source are even stronger; for it so very closely resembles 
the plasma of the blood, that in many cases no difference 
whatever can be detected, and, indeed, we can imitate the 
fibrinous fluid by quickly filtering frog's blood through fine 
tissue paper. Hence, we are led to the view that, in this 
case, even more decidedly than in the serous form, there is a 
purely mechanical permeation of the plasma through the 
walls of the vessels. We must not, however, forget that 
the fluid sometimes appears more dilute, and, as a general 
rule, contains rather less fibrin and albumen than the plasma 
of the blood. Hence, in such cases, as we have already 
seen, endosmotic action is called into play, only to a less 
degree than in serous dropsy. Since the serous, and also the 
fibrinous fluids, take their origin from the blood, and are pro- 
duced by the permeation of its fluid constituents through the 
walls of the vessels, how is it that in some cases we have 
one, and in others, the other form of effusion ? In the 
present state of our knowledge, this question cannot be 
satisfactorily answered ; there is, however, every probability 
that it admits of this solution : namely, that serous dropsy, 
as we have already stated, owes its origin to a permeation of 
the fluid of the blood through the walls of the veins, while 
fibrinous dropsy arises from a similar permeation through the 
walls of the capillary system. 

In favour of this view may be urged : firstly, the 
different properties of the walls of these two divisions of the 
vascular system. The veins have thick walls, consisting of 
several layers of cells and fibres, while the walls of the 
capillaries are very thin and delicate. It is true, that we 
cannot accurately estimate the differences in their endosmotic 
properties, but from analogy (from all the experiments that 
have been made in this department), we may conclude that 
the product of endosmosis, in the former case, is more dilute 
and poorer in solid constituents ; and that in the latter, it is 



DROPSIES. 



51 



more concentrated and abundant in them. Secondly, as we 
have already shown that serous dropsy is associated with 
dilatation of the veins and attenuation of their walls, so we learn 
from microscopic examination of the capillary system, that a 
dilatation of those vessels and an attenuated condition of their 
walls, precedes, and is associated with the occurrence of the 
fibrinous fluid, either in the parenchyma of an organ, or in a 
cavity. The simultaneous occurrence of the effusion, and 
the modified condition of the vessels is, however, so constant, 
that we may conclude with all the certainty possible in such 
cases, that the dilatation of the capillaries is the cause 
of the effusion. It naturally follows, that in the gradual 
transition of the capillaries into veins, there is no rigid limit 
between fibrinous and serous dropsy, and that one may easily 
merge into the other. Further, many causes producing a 
dilatation of the capillaries can likewise act in a similar man- 
ner on the veins ; hence the two processes are very frequently 
associated together ; and thus, in the fluid of serous dropsy, 
we very often meet with small quantities of fibrin. 

In serous dropsy, the causes of venous dilatation are fre- 
quently mechanical, and are, consequently, included in the 
department of pathological anatomy. Not so with fibrinous 
dropsy. Here the dilatation is dependant on dynamic 
causes, whose investigation would, of necessity, lead us far 
into the department of nervous pathology. We should, 
moreover, be led to the consideration of many other pheno- 
mena, as, for instance, the stoppage of the blood in the 
dilated capillaries, which will be considered in another place. 
I restrict myself, therefore, at present, to the mere statement 
that fibrinous dropsy is essentially dependant on the capillary 
system ; that it is associated with, and for the most part arises 
from a dilatation of those vessels, and a tension and attenua- 
tion of their walls. 

The consequence of this process, in relation to the patho- 
logy, as well as to the physiology of nutrition is so great 
that, in point of importance, there is scarcely any other that 

E 2 



52 



DROPSIES. 



can be compared with it. All nutrition depends on an 
effusion of fibrinous fluid into the parenchyma of organs, and 
the transition from the normal state into a morbid con- 
dition is so imperceptible, as to render any line of rigid 
demarcation an impossibility. And, as the process admits of 
being associated with many others, it has received a variety 
of appellations. Many portions of the process of inflam- 
mation, may be referred to it. The so termed exuda- 
tion, and the effusion of plastic lymph are nothing more 
than the result of this same process, and the general 
nutritive fluid which we term, " exudation, or plastic 
lymph," is nothing more than the fibrinous fluid now under 
consideration. I have made this brief statement with the 
view of avoiding unnecessary repetition ; I shall subsequently 
have occasion in many places to take up the thread, which I 
for the present drop, and pursue it further. 

The subsequent fate of the fibrinous fluid may be much 
varied ; and the course it may take is of high pathological 
significance. It is mainly dependant on two principal con- 
ditions : firstly, the fibrinous fluid being coagulable, coagu- 
lation may occur while the fluid is still in the body ; and, 
secondly, as it admits of plasticity, and it may act as a 
cytoblastema for organic formations. Both these points 
require a full consideration. 

The fibrinous fluid may remain unchanged in the body for 
days, or even weeks ; and then coagulate on its discharge and 
behave in the manner already mentioned. In other cases, 
however, the fibrin coagulates in the body itself. It then 
forms a coagulum of more or less firmness ; which, under the 
microscope, appears either perfectly amorphous, or exhibits a 
confused fibrous, or radiating appearance ; and is sometimes 
covered with a finely granular, or pulverulent matter. # If the 
fluid is effused in the parenchyma of an organ, these coagula 
fill all the interstices between the elementary parts of the 



* See pi. ii. figs. 2 and 3 ; and pi. in. fig. 5. 



DROPSIES. 



53 



tissue surrounding them, just as solidified mortar does the 
stones of a wall, and forming with them a compact, appa- 
rently homogeneous mass, in which the original elements of 
the tissue can only be rendered visible by the action of 
acetic acid or ammonia, which dissolve the coagulated fibrin. 
In the cavities, on the other hand, these coagula occur as 
flocculent, or filamentous masses, either attached to the walls 
of the cavity, or, occasionally, swimming unattached in 
the fluid ; or the fibrin may be deposited in layers on the 
walls of the cavity, forming membranous patches. These 
membranes occasionally form a perfectly closed sac within 
the cavity ; indeed, there may be several such sacs of coagu- 
lated fibrin lying one within the other. This is the origin 
of encysted dropsy, and of many forms of hydatids. When all 
the fibrin dissolved in the fluid has assumed the coagulated 
condition, and has become perfectly isolated, then the re- 
maining fluid in every respect corresponds with that of 
serous dropsy, and, consequently, the older observers regarded 
all these as cases of " hydrops serosus." 

The question, why the fibrin in many cases remains for a long time 
fluid, whilst in others it rapidly coagulates, and on what its coagulation 
in the latter cases is dependant, cannot at present be satisfactorily 
answered, any more than we can state with certainty, why the blood 
coagulates after its removal from the body. The most satisfactory 
reason is doubtless a chemical one, although at the same time certain 
influences of the organism seem also to be in play. Just as difficult is 
the explanation how and why fibrin in its coagulation assumes such 
very different forms.* On allowing a fibrinous fluid to remain in a 
state of repose, the whole mass at first assumes the consistence of a 
tremulous jelly ; the fibrin then collects together and forms a species of 
clot, whereby a portion of the fluid contained in it is mechanically 
pressed out, and separates as serum. If, on the other hand, the fibrinous 
fluid during its coagulation is stirred with a rod, or is shaken with 
solid bodies, as fragments of glass, &c. in a stoppered bottle, the fibrin 
then assumes a filamentous, or membranous form on the solid bodies. 

* A very instructive account of the various relations influencing the 
coagulation of fibrin, is given in Henle's Report : Zeitschr, fur rationelle 
Medic, vol. n. p. 168, &c. 



54 



DROPSIES. 



From these acknowledged facts, and with the aid of experiments on the 
dead body, we may draw many conclusions respecting the mode in 
which fibrin coagulates in the living body. A perfect coagulation of the 
fibrin (such for instance as to form a jelly), never or very rarely occurs 
within the body. The comparatively frequent cases where an apparently 
gelatinous exudation occurs, as for instance, on the surface of the pleura, 
do not fall under this head : they consist merely of serum, with which 
the fibres of the serous membrane are infiltrated. Experience teaches 
us that the coagulation of the fibrin takes place more slowly within 
than without the body, and hence it is probable that the organic parts 
exert a certain attractive power on the fibrin, such as the glass rod 
seems to do during the process of stirring. Further, the organs of the 
body are seldom in a state of absolute repose, but in a manner imitating 
the action of stirring, which we adopt in the artificial separation of the 
fibrin. Thus, in the cavities we find stratified depositions of coagu- 
lated fibrin. As coagulation within the body takes place very slowly, 
these layers are extremely thin ; a layer, a line in thickness, of coagulated 
fibrin may be divided into twenty or more separate and distinct strata. 
From the regularity and similar thickness of these layers, it cannot be 
doubted that they have been successively deposited by the fluid, so that 
the outer layer (that namely in apposition with the serous membrane) 
is the oldest. As a further argument in favour of this view, it may be 
added that the external layer is the first that becomes organized. 

If, moreover, we bear in mind that in many cases the separation of 
the fibrinous fluid from the capillaries is very gradual, and further, that 
it does not occur equally at all points of a serous membrane, (as for 
instance, the pleura or peritoneum) we can easily understand why some 
parts of these membranes are covered with layers of coagulated fibrin, 
while others are not. In such cases, the fibrin coagulates at the points 
at which it exuded, depositing itself on the serous membrane, and 
forming slight elevations on it. The subsequent exudation seems to be 
chiefly deposited on these elevations, which, like foreign bodies, act as 
points of attraction, and in this way there are formed tufts, flocculi, 
&c. This affords us an easy explanation of the formation of the cor 
villosum, and other singular forms of coagulated fibrinous exudations, 
without any necessity for having recourse to electricity, &c, as has been 
done by Eisenmann, who fancies that in these forms he can detect 
electric figures.* 

As long as the fibrinous fluid is not coagulated, it may, like 
the serous fluid, be resorbed, and either entirely or in part 
disappear, or become more concentrated ; and the resorption 



* Haser's Archiv. vol. i. Part in. p. 373. 



DROPSIES. 



55 



proceeds with a greater facility than in the former case, 
there being commonly no hindrance to the activity of the 
venous system. 

But if the fibrin has once coagulated, then the resorption 
can only extend to the serum ; hence, in consequence of 
their loosing a portion of the fluid enclosed in them, the 
fibrinous coagula become tougher and firmer. The coagu- 
lated fibrin can only disappear by undergoing an organic 
change, as will be shown in the following section. Whether 
it cannot be rendered fluid, and then gradually resorbed 
by chemical means, as, for instance, by the use of iodine, 
and other similar remedies, must, for the present, remain 
unanswered questions. 

The dropsical fluid, enclosed in a sac of coagulated fibrin, 
is in a manner cut off from the resorbent vessels — the veins 
and lymphatics ; and its resorption is a more difficult and 
tedious process than if it were not thus enclosed. This 
explains the unyielding character of encysted dropsy. 

The fibrinous fluid is capable of organization, which is 
always effected at the expence of the fibrin contained in it. 
It constitutes the peculiar cytoblastema ; hence there is no 
developmental capacity in the fluid of serous dropsy in 
consequence of the absence of fibrin. As far as development 
is concerned, it is indifferent whether the fibrin is in a fluid 
or coagulated state, as in either case it acts equally well as a 
cytoblastema, and its capacity is unlimited, that is to say, there 
may be evolved from the fibrin the most different forms of 
tissue, either normal, as cellular tissue, simple muscular fibre, 
cartilage, bone, vessel, nervous fibre; or pathological, as, pus, 
granular cells, cancer, tubercle, concretions, &c. The process 
of development invariably follows general laws, whose bearings 
I have attempted to investigate in the following section on 
pathological epigeneses. Through this capacity for organi- 
sation, fibrinous dropsy becomes the common source of a 
great variety of morbid growths, as will be shown in the sub- 
sequent chapters. 



56 



DROPSIES. 



The first indication of the developmental process in the coagulated 
fibrin, is the formation of cells : till then it is amorphous. Sometimes 
the fibrinous coagula attached to the serous membranes contain cells of 
an earlier formation ; these, however, are not developed from the fibrin, 
but appertain to the epithelium of the serous membrane, and having 
been thrown off during the process of exudation, have thus become en- 
tangled in the coagulating fibrin. This is especially frequent in recent 
exudations into the pericardium, and in all probability the case described 
and illustrated in pi. n. fig. 4, belongs to this class. 

The fibrin appears to undergo no essential change in its elementary 
composition by the act of coagulation ; subsequently,* however, certain 
chemical changes do occur in it. I postpone their consideration to one 
of the following sections. 

Diagnosis of fibrinous dropsy, and anatomical relations 
of the surrounding parts. — The fluid is sufficiently charac- 
terised by its containing dissolved fibrin, and by its sponta- 
neous coagulation after removal from the body. The diag- 
nosis can only be doubtful when a serous fluid contains a 
considerable quantity of blood, as sometimes happens from 
the operation of paracentesis ; for a serous fluid, mixed with 
one third or one fourth, its quantity of blood, after a time 
likewise gelatinizes. If, however, the amount of blood is 
not so considerable (and this may be decided by the colour 
and the quantity of the blood-corpuscles), then the coagula- 
tion of the fluid is a certain sign that the dropsical effusion 
contained dissolved fibrin. If the fibrin has coagulated within the 
body, the diagnosis is rendered certain by the following tests : 
by the appearance of the coagulum under the microscope ; by 
its becoming transparent on the addition of acetic acid or 
ammonia; by its dissolving in caustic potash, and by the 
liquid in which it floats resembling that of serous dropsy. 

The surrounding parts are usually reddened, and when 

* Von Fellenberg, (Fragments de recherches comparees sur la nature 
constit. de differ, sortes de fibrine du cheval. Berne, 1841), believes, 
however, that he has proved by his ultimate analyses, that it loses the 
elements of hydrogen ; or of oxygen and hydrogen in the proportion to 
form water ; a view which being opposed to the experiments of Scherer 
and others, at all events requires further confirmation. 



DROPSIES. 



57 



examined under the microscope, their capillaries appear to be 
distended and filled with blood.^ 

When the parenchyma becomes infiltrated by the fluid, 
there is at first a soft, doughy swelling, such as occurs in 
serous dropsy; when, however, the fibrin coagulates, the 
tumour becomes hard, and, on making a section through it, 
appears firm and lardaceous. Since, however, in inflamma- 
tory affections of the external organs, the fibrinous fluid is 
usually poured forth very gradually from the capillaries, the 
first portion coagulates before the second is effused ; hence, the 
tumour is commonly firm and resistent from the time it is 
first observed. 

When effusion takes place in a serous cavity, it gives rise 
to distention of the enclosing membrane ; and, hence, to 
compression of the surrounding parts. 

The fibrinous effusion is of most common occurrence after 
pleuritis, or pericarditis ; it is more rare after peritonitis suc- 
ceeding paracentesis. In the dead body it is usually found in 
a coagulated state. 

3. FALSE DROPSY. 

In the early systems of pathology, many cases were 
regarded as dropsies, in which fluids collected in the secreting 
organs, or in their discharging passages, in consequence of 
some impediment to their exit. Thus, we read of dropsy 
of the kidneys (hydrops renum), of the uterus (hydrometra), 
of the fallopian tubes, of the gall-bladder, of the appendix 
vermiformis of the caecum, and of the lachrymal sac. These 
dropsies belong neither to serous nor to fibrinous dropsy. 
They arise from the duct of the secreting organ being, in 
some part of its course, either temporarily or permanently 
closed. In consequence of this impediment, the fluid accu- 
mulates in the secreting organ, and in its discharging duct 
as far as the obstruction, distending those parts. The fluid 
in this form of dropsy, is, therefore, originally identical with 

* See pi. ii. fig. 1. 



58 



DROPSIES. 



the secretion which has thus given rise to the tumour ; in the 
kidneys it is urine; in the intestines, uterus, and fallopian 
tubes, it is a product of the secretion of the mucous membrane, 
&c. If the obstacle continues for any length of time, the 
secretion undergoes certain changes, becoming modified by 
the endosmotic action that is set up between it and the sur- 
rounding fluids. Hence, for instance, the fluid of dropsy of 
the kidneys (hydrops renum) is not always identical with 
normal urine. 

The particulars respecting the different forms of these false dropsies 
may be found in the special part of our treatise, under the individual 
organs. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 



59 



CHAPTER III. 

PATHOLOGICAL RELATIONS OF THE BLOOD, 

The blood of the human body may in various ways deviate 
from its normal condition. The following may be regarded 
as the most important deviations : 

1. Its physical and chemical characters may undergo 
alteration. It may be either thinner or thicker than usual, 
and its colour may be affected. The blood-corpuscles may 
appear changed. The proportion of its constituents to each 
other may be altered, and it may contain matter not nor- 
mally existing in it, as sugar, free lactic acid, &c. 

2. Its quantity may be increased (hyperemia or polyhsemia) 
or diminished (anaemia or hypaemia) . This increase or diminu- 
tion may either be general, extending to the whole organism, 
or local, and restricted to particular parts of the body. 

3. It may be effused in consequence of laceration of the 
blood-vessels, into the interstices of the parenchyma of 
certain organs, or into some of the cavities of the body, con- 
stituting extravasation. 

4. The hsematin may, by a process of decomposition, be- 
come dissolved, and then be imbibed by the tissues. 

1. PHYSICAL AND CHEMICAL CHANGES OF THE BLOOD. 

Deviations in the physical and chemical characters of the 
blood are of very frequent occurrence. We find them in the 



60 PATHOLOGICAL RELATIONS OF THE BLOOD. 



body after death, just as they are observed during life when 
blood has been taken by venesection or other means ; and 
yet, until recently, the statements of most authors respecting 
these changes are extremely indefinite and unsatisfactory, ren- 
dering it alike difficult to attach any certain meaning to their 
facts, or to discover their causes or signification. Moreover, there 
is hardly another department in the whole range of medical 
science which has been so frequently used as a foundation 
for false hypotheses and theories relating to pathology and 
therapeutics — hardly another on which the majority of the 
profession entertain such obscure views and vague ideas as 
on the pathological changes of the blood. Hence, on this 
subject, the necessity for thoroughly determining the rigid and 
exact truth is doubly necessary. 

The above changes may be arranged under two divisions, 
in accordance with the means requisite for their detection ; 
firstly, such as are directly obvious to the senses, and are 
especially noticed in pathologico-anatomical researches on 
the dead body. These are principally modifications in 
its physical characters, as in the colour, consistence, or nature 
of the coagulation. Secondly, such as for their detection re- 
quire certain processes, often of a complicated nature — as most 
of the deviations of a chemical character. 

In accordance with the plan stated in my Introduction, I shall say 
nothing of the physiological or vital phenomena of the blood. But the 
changes in the blood which are recognizable by the senses, belong 
strictly to pathological anatomy, and with respect to the chemical 
changes, I certainly think that the most important, if they are suffi- 
ciently confirmed, should not be excluded, even if they appertain less to 
pathological anatomy than to chemistry. But it is the task, and fortu- 
nately also the tendency of the present day, to unite these two 
sciences. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 61 



DEVIATIONS IN THE PHYSICAL CHARACTERS OF THE BLOOD. 

Change in colour. — Arterial blood in a normal state 
is, as is well known, of a bright red, while venous blood 
is of a dark red colour, with a shade of blackish brown. 
Any attempt at an accurate estimation of these shades of 
colour, and of the associated pathological conditions, by mere 
description, must of necessity be vague and unsatisfactory. 
To obtain accurate results of this sort, we should draw up 
certain colour-tables, such as are used in the cyanometer for 
the purpose of estimating the blue tint of the sky. Hence, 
the statements hitherto made respecting the changes of 
colour noticed in the blood are very unsatisfactory. The 
following are the most important of these changes. Varia- 
tions in the colour of arterial blood have been seldom 
noticed, and little is known regarding them, in consequence 
of the few opportunities that present themselves of examining 
that form of blood. In cases of cyanosis, where the venous 
and arterial currents become partially mixed, in consequence 
of a portion of the former not passing through the lungs, but 
going through the patent ductus botalli, foramen ovale, 
or a perforation of the wall separating the ventricles, it is 
commonly darker than in the normal condition. A similar 
condition is probably established in those pulmonary diseases 
in which, although the passage of the blood through the 
lungs is not impeded, the free contact of the blood and 
atmospheric air is disturbed, as in oedema pulmonum. Here the 
cause is sufficiently obvious. It consists of a limitation of 
those shades of colour which the venous blood naturally 
acquires in its passage through the lungs. It is seldom 
clearer, but often of a darker colour than in the normal state. 
Venous blood is sometimes observed with a bright red tint in 
cases of scurvy ; # this is probably dependant on an increased 
amount of saline matter, which as is known, communicates 



Lobstein, path. Anat. vol. n. p. 537. 



62 PATHOLOGICAL RELATIONS OF THE BLOOD. 



that tint to the blood. I have sometimes noticed venous 
blood of a bright red colour, with a shade of blue, much the 
tint that is developed on treating uric acid with nitric acid 
and ammonia : thus, in the dissection of an arthritic subject, 
the blood of the renal veins presented this tint. In other 
cases, the venous blood appears dark, of a brownish red or 
almost black colour, sometimes even resembling tar or ink. 
These variations in colour are often associated with other 
physical changes, as an abnormal increase or diminution of 
density, &c. They are, however, never so constant as to 
permit of our always finding the same tint in the same 
disease, nor can we recognise their causes with any degree of 
certainty. In fact, the causes of the tints proper to healthy 
arterial and venous blood are not altogether established. 
Hence, no great importance should be attached to any pecu- 
liar colour presented by the blood, and still less should 
any conclusions be drawn from them, at least, until we are in 
a better condition than we now are to recognize with cer- 
tainty the cause of such a change in each individual case. 

With respect to the causes of the difference in the colour of arterial 
and venous blood, see H. Nasse's Article in Wagner's Handworterbuch 
der Physiologic vol. i. p. 181, &c, where all that we at present know 
on the subject is clearly described and criticised. The colour of the 
blood is modified by the action of many different substances, and we 
possess a great amount of information respecting these artificial 
changes ;* but even the very circumstance that so many causes pro- 
duce a similar colour, renders the determination of the cause in an 
individual case, a matter of much greater difiiculty. 

The colour possessed by fresh blood remains after coagu- 
lation and the separation of the coagulated blood into the 
clot and expressed serum. The former retains the original 
colour, but, after a time, the surface usually assumes a 
brighter tint from the action of the oxygen of the atmos- 

* Compare Berzelius, Thierchemie, 4th Edit. p. 72, &c. ; Simon's 
Animal Chemistry, vol. i. p. 112; and especially Hiinefeld, der Che- 
mismus in der thier. Organisation, p. 117. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 63 



phere. In the normal state, the serum is colourless, but it 
frequently exhibits a brownish green, or yellow tint. This 
yellow, yellowish green, or brown colour of the serum, may 
depend on two distinct causes. 

Li On bile-pigment. — In this case on treating the serum 
with nitric acid, the well-known changes of colour are pro- 
duced : a little acid renders the serum green ; a larger quan- 
tity, blue, purple, violet, and lastly of a dull red or yellow 
colour. This reaction is, however, usually somewhat modi- 
fied by the presence of the albumen of the serum, which is 
precipitated by the acid, and subsequently assumes a yellow 
tint, which conceals or modifies that of the altered bile-pigment. 
A large amount of this pigment is always present in cases of 
jaundice, when not merely the blood, but also the other 
fluids and secretions, and even the parenchyma of the different 
organs become of a yellow tint. This may, however, occur 
without jaundice in persons apparently healthy. I have seen 
a large amount of bile-pigment in the serum of an old man, 
who was not jaundiced, in whose case venesection was ordered 
in consequence of apoplectic symptoms, and a smaller, but 
still very considerable quantity in the serum of a man with 
arachnitis. 

2. The yellowish green or brown tint of the serum may 
be dependant on the brown colouring matter of healthy 
blood, which was first described by Simon, and received the 
name of hcemaphain from that chemist. # Nitric acid will 
serve to prevent its being mistaken for bile-pigment. 

The, serum which in a normal state ought to be clear, is 
sometimes opaque and of a milk-white appearance. This 
may depend on various causes. Firstly, on a large number 
of microscopic fat-vesicles. Secondly, on the presence of a 
considerable quantity of minute granules of coagulated fibrin, 

* For a description of hsemaphsein, see Simon's Animal Chemistry, 
vol. i. p. 42. 



64 



PATHOLOGICAL RELATIONS OF THE BLOOD. 



as has been observed by Scherer and Simon. # Thirdly, pro- 
bably also on the formation of a free acid in the blood, whereby 
a portion of the albuminate of soda becomes decomposed, and 
albumen, in a finely granular form, becomes separated. The 
turbidity dependant on the presence of fat is sometimes 
observed in perfectly healthy persons, shortly after partaking 
of an abundant meal, when the blood is receiving a large 
quantity of chyle. Turbidity, arising from coagulated fibrin, 
was observed by Scherer in a pregnant woman with bronchitis 
tuberculosa, in a leuco-phlegmatic person suffering from 
attacks of vertigo, and in a spirit-drinker with cerebral con- 
gestion ; Simon noticed it in a man with Bright's disease. 
It would appear as if this separation of the fibrin in a granular 
form, were owing to some peculiarity in its mode of coagu- 
lating. The causes of the turbidity in these cases may be 
readily detected by the microscope ; the fibrin-granules dissolve 
in acetic acid and in a solution of nitrate of potash ; the fat- 
vesicles which may be recognised by their peculiar form, 
are not soluble in these fluids but dissolve in ether. The 
serum sometimes appears reddened in consequence of blood- 
corpuscles being suspended in it ; this is chiefly noticed when 
the coagulation is imperfect ; it occasionally, but more rarely, is 
dependant on a solution of the hsematin, of which we shall 
speak presently. 

The changes in the consistence of the blood are likewise 
very imperfectly understood, and the statements on this 
subject are as indefinite as they are uncertain, since we have 
no proper means of determining with accuracy the degree of 
consistence of this fluid. Our information is limited to this, 
that we sometimes find the blood thinner than in the normal 
condition, sometimes thicker and more viscid ; a change of 
consistence is usually associated with a modification in the 

* Untersuch. p. 85 and 87. Simon, Beitrage z. physiolog. und 
patholog. Chemie, p. 287 ; Zimmermann zur Analysis u. Synthesis der 
pseudo-plastischen Processe, p. 100, &c. 



PATHOLOGICAL RELATIONS OF THE BLOOD, 65 

colour of the blood. According to Lobstein,^ the blood is 
thinner than usual in scurvy, in morbus maculosus Werl- 
hofii, in typhus, in petechial fever, in malignant pustule, 
in scarlatina, and in measles. It was likewise noticed by 
Schererf in puerperal metritis. It appears thicker than usual 
in cholera, in consequence of the amount of water in the 
blood being much diminished. Generally speaking, our 
information respecting the variations in the consistence of the 
blood are of little value, because their determination has not 
been based on accurate principles ; and they are even more 
unserviceable and deceptive when they refer, not to fluid blood 
escaping from the living body, but to the entirely or partially 
coagulated blood found on dissection, since the original 
degree of consistence existing during life is already mo- 
dified. 

This leads to the consideration of deviations in the coagu- 
lation of the blood. The blood coagulates out of the body 
in the same manner as in the body after death. In each 
case the process is essentially the same, although, in the 
latter there are so many modifying circumstances that it is 
better that we should consider each phenomenon separately. 
Blood obtained from the living body, either by opening a 
vein, or by any other means, may present the following 
peculiarities in its coagulation. 

1 . The blood may coagulate very rapidly, or, on the other 
hand, not for some time after its discharge : in some cases 
it occurs in one and a half minutes ; in other cases it onlv 
commences after the lapse of fifteen or twenty minutes. 
This acceleration and retardation of the coagulation cannot 
be well accounted for ; and the causes influencing the rapidity 
being apparently very complicated, no practical conclusions can 
as yet be drawn from these phenomena. It appears that it is 
hastened, and, indeed, principally caused by the action of the 



* Path. Anat. vol. n. pp. 539. t Op. cit. p. 160 and 163. 
VOL. I. F 



66 PATHOLOGICAL RELATIONS OF THE BLOOD. 



atmospheric oxygen ; # on the other hand, it is well known 
that the artificial addition of many salts to fresh blood 
retards the coagulation. Hence we must conclude that a 
slow coagulation is frequently dependant on an increase of the 
salts. According to H. Nasse, the blood of the common 
hen and the goose, which is very slow in coagulating, con- 
tains from one third to one half more salts than human 
blood.f In every case the cause of the difference appears to 
be chemical, and not vital. 

2. Many deviations occur in the consistence and other 
properties of the clot, as well as in the proportion of its 
volume to that of the serum. The clot is sometimes very 
tough and firm, difficult to break up, and offering a resistance 
to the knife ; in other cases, it is very soft and loose, forming 
a slightly consistent gelatinous mass, like currant jelly, 
breaking up on the slightest touch ; in some cases it even 
happens that no true clot is formed, the blood remaining 
fluid, and, after standing for some time, merely forming a few 
soft, flocculent coagula. These are the two extremes, between 
which there may be many intermediate degrees. These dif- 
ferences are dependant on the condition of the fibrin, and in 
part, also, on its quantity. In proportion to the coagulating 
tendency possessed by the fibrin, and to its quantity, so 
much the firmer and more solid is the clot, which, in this 
way furnishes us with an approximation to the amount of 
fibrin present. These modifications of the fibrin may depend 
on various causes, all, however, of a chemical nature. The 
most frequent cause is the same that retards the coagulation, 
namely, an increase of the salts ; in extreme cases, when, 
for instance, no coagulation takes place, it depends on an 
increase of the alkaline carbonates. The salts, when arti- 
ficially added, lessen the tendency to coagulation, and the latter 

* See Nasse's Article in Wagner's Handworterbuch, &c, vol. i. 
p. 112. 

| Op. cit. p. 114. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 67 

(the alkaline salts) altogether destroy it. Thus, in a case of 
putrid typhoid fever, Scherer* found carbonate of ammonia 
in the blood, which was black and pitchy, and did not coagu- 
late into a solid clot, but merely formed a diffluent saline 
mass. 

The presence of the carbonate of ammonia was shown by the deve- 
lopment of a white vapour on holding a glass rod moistened with 
non-fuming hydrochloric acid over the blood; and further by the 
circumstance, that the blood distilled on the water-bath yielded a fluid 
which had an alkaline reaction, and frothed on the addition of an 
acid. 

The volume of the clot to that of the serum differs 
extremely in different cases; sometimes the clot is small, 
while above it there is a very considerable quantity of serum ; 
sometimes it is large, occupying nearly the whole volume of 
the blood, while only a very small quantity of serum is 
separated. These proportions, like those we have just con- 
sidered, are also dependant on the coagulability of the 
fibrin, which stands in a direct ratio to the compactness of 
the clot, and to the amount of serum expressed from its 
interstices. Hence the presence of a large amount of 
serum must not lead us to infer that the blood contained an 
excess of water ; neither is a large clot to be regarded as a 
certain indication of the presence of an excess of fibrin. 

The coagulated fibrin of the blood likewise exhibits diffe- 
rences in its chemical relations. Such differences occur in 
health between the fibrin of arterial and venous blood ; thus, 
venous fibrin gradually dissolves in an aqueous solution of 
nitrate of potash, while arterial fibrin is insoluble in that 
menstruum. In inflammatory affections, however, the coagu- 
lated fibrin of venous blood is frequently insoluble in that 
solution. This a point worthy of consideration. 

3. Coagulated blood sometimes exhibits on its surface 



* Untersuch. p. 68. 

f2 



68 PATHOLOGICAL RELATIONS OF THE BLOOD. 



what is termed the huffy coat (crust a phlogistica seu pleu- 
ritica). We may explain its formation in this way, that in 
this case the blood-corpuscles began to sink before the 
occurrence of coagulation, so that the upper surface of the 
clot, enclosing no blood corpuscles, appears colourless, and 
consists of mere fibrin. Several causes may tend to produce 
this deposition of the blood-corpuscles previous to coagula- 
tion ; thus, sometimes, they sink more rapidly than usual 
from their arranging themselves in columns resembling 
rolls of coin, and thus overcoming the resistance of the 
plasma, on the same principle that large bodies sink through 
a fluid more rapidly than small ones ; sometimes the blood 
appears to coagulate more slowly than usual ; and not unfre- 
quently both causes are in operation. We frequently observe 
an increased quantity of fibrin in blood with the buffy coat ; 
but the increase of that constituent is not the cause of the 
buff, and the opinion that the formation of a buffy coat is 
always a sign of inflammation, and that, consequently, further 
venesection is necessary, is utterly false, and has led to very 
disastrous practical consequences. * 

The variations occurring in the coagulation of the blood in 
the body after death cannot be easily explained, and the 
observations that have been recorded on this point are of 
little or no value, in consequence of the causes of their varia- 
tion not being at the same time indicated. Generally 
speaking, on examining the body after death, we find the 
blood in the capillaries fluid ; while in the heart and veins, it 
is coagulated, the arteries being frequently empty. The 
fluidity of the blood in the capillaries is not dependant on a 
deficiency of fibrin, for blood taken from the capillaries after 
death, frequently coagulates in the course of twenty-four 
hours, or even later. It is very possible, as has been sug- 
gested by Nasse,f that the exclusion of the atmospheric air 

* Compare Nasse, das Blut. p. 36 and p. 204, &c. 
t Handworterbuch der Physiolog. vol. i. p. 113. 



PATHOLOGICAL RELATIONS OF THE BLOOD, 69 



tends to retain the fibrin in a state of fluidity. Although the 
coagulated blood in the heart and large vessels of different 
bodies presents different properties, it has been found im- 
possible to deduce any general laws on the subject. Coagu- 
lation within the vessels is never so perfect, nor the clot 
so firm as when the coagulation takes place out of the 
body. The condition of the blood, or at least of the fibrin, 
previous to death, obviously exerts a great influence on the 
condition of the subsequently formed coagulum. The heart 
not unfrequently contains white or yellow coagula of fibrin, 
with few or no enclosed blood-corpuscles. These coagula 
sometimes extend from the heart into the large arteries ; 
more rarely into the large venous trunks. It is not very 
easily seen, how so perfect a separation of the plasma from 
the blood-corpuscles can take place after death, that the fibrin 
for the most part shall coagulate alone, without including 
blood-corpuscles ; and hence it is most probable that when 
the fibrin has a tendency to coagulate, these white coagula 
are ready formed during life in the death-struggle. The con- 
tractions of the heart, and the pulsation of the arteries exert 
in these cases an influence on the blood, similar to that artifi- 
cially produced by stirring with a glass rod, and thus the 
fibrin is separated and forms white coagula. I am con- 
firmed in this opinion, from having repeatedly found tough 
white coagula in the heart, in cases where some days 
before death, syncope with disturbed cardiac action has 
supervened.^ The blood in the heart and large vessels is 
either fluid or very imperfectly coagulated in cases of death 
from lightning, from various sorts of poison, in scurvy, in 
many cases of typhus, and in putrid fevers. Although this 
condition is obviously dependant, (like the analogous relations 
of the blood out of the body), either on a diminution of the 
fibrin, or on that constituent having lost its power of coagu- 



See the description of fig. 3 in pi. n 



70 PATHOLOGICAL RELATIONS OF THE BLOOD. 



lating, we are not at present in a condition to state with any 
degree of certainty the chemical causes of these changes. 
Consequently we are not yet in a condition to draw any 
valuable inferences from the changes undergone by the blood 
in the dead body. 

Changes in the odour and taste of the blood have been 
noticed by different observers ; thus the taste of the blood of 
syphilitic women has been observed to be saline; of jaun- 
diced persons, bitter ; and in cases of rachitis, acid ; # in scurvy 
and putrid fever, it has a putrid odour ; and Barruel even 
asserts, that from the odour developed on the addition 
of sulphuric acid, he can distinguish the blood of man 
from that of woman, and recognise the blood of different 
animals. Experiments of this nature in respect to the taste 
and odour of the blood are generally of trifling importance, 
although the former might be serviceable in the detection 
of odorous matters, not easily recognised by tests, in the 
blood : as for instance, alcohol, phosphorus, hydrocyanic 
acid, &c. 

Changes in the blood-corpuscles. — It is well known that 
the blood-corpuscles undergo numerous changes, when 
brought in contact with various reagents, as well as 
during the decomposition and putrefaction of the blood.f 
Numerous as these changes are, the causes producing them 
may be referred to two distinct types. Firstly, they may 
be of a merely physical character, and dependant on endos- 
mosis or exosmosis, as when the blood is diluted with water, 
or mixed with a concentrated saline solution. In the former 
case, the blood-corpuscles become tumid, and the central 
depression disappearing, they cease to be biconcave and 
become spherical. In the latter case, they become contracted, 
irregular and indented at the edges, or present the appearance 

* Lobstein, Path. Anat. vol. n. p. 540. 

t For the most perfect account of these changes, see Hiinefeld, der 
Chemismus in der thier. Organisation, p. 43, &c< 



PATHOLOGICAL RELATIONS OF THE BLOOD. 71 

of being surrounded with a festoon of minute granules. 
Secondly, the changes may be of a chemical nature, since many 
substances enter into combination with, or dissolve certain 
constituents of the blood-corpuscles. Thus water dissolves 
their colouring matter, causing them to become transparent, 
and ultimately to disappear ; nothing but the nuclei (when 
these are present) remaining. Moreover, acetic acid, ammo- 
nia, and the other alkalies dissolve the corpuscles. Changes 
of this nature rarely occur in the living body, but frequently 
after death. 

The most common change noticed in fresh blood, just 
drawn from a vein, is this, that some of the corpuscles appear 
tumid and spherical, or else contracted, irregular or studded 
with granules. This appearance as we have already observed 
may be explained on the principles of endosmosis and exos- 
mosis. # Even this change is of rare occurrence. 

In the dead body these changes are of more common 
occurrence. Thus Schererf found that the corpuscles of the 
blood, contained in the heart of a woman who died from 
puerperal metritis, were swollen and indented at the edges y 
the blood contained free lactic acid, and chemical decompo- 
sition had therefore already commenced. In gangrenous 
parts, I have frequently observed that the greater number of the 
corpuscles were entirely dissolved, not a trace of them being 
left. In all these cases we may conclude that the modifica- 
tion of the blood-corpuscles is dependant on the influence 
of a chemical change in the blood; the nature of this 
change must be determined by chemical analysis, since 
very different reagents produce similar changes in the cor- 
puscles. Sometimes these chemical changes and the conse- 
quent alteration in the form of the corpuscles, do not com- 
mence till after death. Thus in typhus, the change in the 

* According to Andral, the raspberry-like appearance of the corpuscles 
is dependant on the adhesion of fibrinous granules to them, 
f Untersuch. p. 160—163. 



72 PATHOLOGICAL RELATIONS OF THE BLOOD. 

blood-corpuscles frequently takes place in ten or twelve hours, 
in consequence of the rapidity with which putrefaction com- 
mences in this disease, as has been frequently observed by 
myself, and confirmed by Gluge. # Duboisf found that 
the blood-corpuscles of scrofulous persons were devoid of 
the proper colour, some having lost it at their edges, 
others entirely; moreover some were more flattened than 
usual, while others presented a tumid and spherical appear- 
ance. 

Changes in the blood-corpuscles may easily be induced by 
diluting the blood with water, or thin syrup, or by the evapo- 
ration of the liquid portion of the serum during the experi- 
ment ; hence, the necessity for great care in such observa- 
tions. 

In microscopic examinations of the corpuscles of defibri- 
nated blood, we sometimes, but not always, observe that they 
indicate a tendency to arrange themselves with their surfaces 
in contact, in forms resembling rolls of coin. This tendency 
is interesting, since it very probably plays a part in many 
pathological phenomena ; thus it favours the formation of the 
buffy coatj since the corpuscles, arranged in this form, sink 
more rapidly than in ordinary cases. Henle§ remarks that 
this arrangement is closely connected with the occurrence of 
inflammation, being the cause of the stagnation of the blood 
in the capillary vessels. Hence it would be of much impor- 
tance to ascertain the cause of their tendency to adhere to 
each other. Henle believes that it arises from an excess of 
albumen, and at the same time a deficiency of salts in the 
serum of the blood. I have instituted several series of expe- 
riments with the view of elucidating this important question ; 
they did not, however, yield any definite results. I was 

* See the chapter on the changes occurring after death, 
f L'Experience, 1839, No. 87. 
t See p. 68. 

§ Henle und Pfeufer's Zeitschr. vol. u. p. 120, &c. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 73 



unable to establish this tendency by the addition of an albu- 
minous solution, devoid of salts ; while on the other hand, by 
the addition of a concentrated saline mixture to blood already 
exhibiting it, this tendency was sometimes, but not invariably 
increased. The point is one of sufficient importance to 
render a further investigation well worthy of being under- 
taken. 

CHANGES IN THE CHEMICAL CONSTITUTION OF THE BLOOD. 

With a few exceptions, all our knowledge respecting the chemical 
changes of the blood has been acquired during the last few years, and 
although it seems to explain several important points, it is still far from 
being in a complete and satisfactory state. In the following observations 
I shall therefore merely bring forward the most important points.* 

The blood in its chemical composition is a very intricate 
fluid, containing a large number of different substances. As 
each of these substances entering into the composition of the 
blood may undergo either a qualitative or quantitative change ; 
and as, moreover, in certain pathological conditions, sub- 
stances not occurring in normal blood may be present, it 
is manifest that the deviations in its composition must 
be very numerous. To make the subject clearer, we shall 
divide them into certain groups. 

1. Any one constituent may be either relatively increased 
or decreased. 

a. The fibrin may be increased. — In 1000 parts of nor- 

* The following are the most important works on this subject : 

Denis, Essai sur l'application de la Chimie a l'Etude physiolog. 
du Sang de 1' Homme, Paris, 1838. 

Lecanu, Etudes chimiques sur le Sang humain, Paris, 1837. 

Andral et Gavarret, Recherches sur les Modific. de Proportions de 
quelques principes du Sang dans les Maladies, Paris, 1840. 

Scherer's Untersuchungen z. Pathologie, 1843. 

Andral's Hematologic 

Simon's Animal Chemistry ; to which may be added the Translator's 
Reports on the Progress of Animal Chemistry, in Ranking's half- 
yearly Abstract of the Medical Sciences. 



74 



PATHOLOGICAL RELATIONS OF THE BLOOD. 



mal blood, there are from one to three parts of dried fibrin ; 
but in certain pathological conditions, it may rise to 5*7, or 
even 10 parts, being more than treble the normal quantity. 
This is the case in most inflammatory affections, and espe- 
cially in most of the cases that give rise to fibrinous dropsy, 
in pneumonia, pleuritis, bronchitis, peritonitis, acute rheu- 
matism, severe erysipelas, and in many cases of pulmonary 
tuberculosis; at the same time we frequently find that the 
qualities of the fibrin are also altered. After coagulation it is 
insoluble in a solution of nitrate of potash, differing in this 
respect from normal venous fibrin, and resembling that of 
arterial blood. 

The fact that the fibrin is thus increased is established 
beyond all doubt, but respecting the causes of this augmen- 
tation, and in part respecting its signification, there is still 
much to be explained. Simon, relying on the observation 
that the quantity of blood-corpuscles is simultaneously dimi- 
nished, conjectures that this increase takes place at their 
expense, and that the fibrin is formed from the hsematoglo- 
bulin. On equal grounds it might be asserted that the fibrin 
is produced from the albumen of the plasma, since we possess 
no certain knowledge respecting the conditions under which 
one protein-compound is converted into another, and respect- 
ing the production of the fibrin in normal blood. Henle # 
has offered another explanation. He believes that the increase 
of the fibrin in all these cases is dependant on an exudation 
from the vessels (our fibrinous dropsy) containing less fibrin 
than the plasma, which thus after the exudation contains a 
relatively larger amount of fibrin than before. But this 
hypothesis fails to account for the great augmentation of the 
fibrin in inflammation, and for its relative increase in propor- 
tion to the quantity of blood-corpuscles. 

A diminution in the amount of fibrin (when for instance it 
falls below 1 in 1000 parts of blood) may either actually 

* Zeitschrift fiir rationelle Medicin v. Henle und Pfeufer, vol. i. 
No. i. p. 119. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 75 

occur, or may be only apparent in consequence of its coagu- 
lation and separation being prevented by an excess of salts, 
or by the occurrence of carbonate of ammonia. 

The amount of fibrin is determined by collecting the fresh blood in a 
weighed vessel, and stirring it with a glass rod of known weight, till 
all the fibrin has coagulated, and either separated in floccules or 
attached itself in the form of membranous shreds to the rod. By- 
weighing the whole, we know the weight of the blood. The blood is 
then strained through a cloth which retains the fibrin that has sepa- 
rated in flocculi. To this we must add the portion adherent to the rod, 
and wash the whole (retaining it in the cloth) till it becomes colourless. 
It must then be dried on the water- bath, its fat removed by boiling in 
ether, and finally weighed. 

b. The quantity of blood-corpuscles may be increased or 
diminished. — Although we have not the means of determin- 
ing the amount of the blood-corpuscles with the same 
accuracy as that of the fibrin, we have yet sufficient evidence 
to show that, like the other constituents of the blood, they 
admit of considerable variation. While every 1000 parts of 
normal blood, contain on an average 127 of dried corpuscles, in 
cases of fever the number may rise to 136, 160, or even to 
185, while on the other hand, in cachectic conditions, and es- 
pecially in chlorosis, it may fall to 100, 80 or even 38.* 
This diminution is associated with morbid processes which 
impede nutrition, but we do not at present possess any in- 
sight into those processes which cause this diminution, those 
cases being excepted in which it is obviously dependant on 
haemorrhage, copious blood-letting, or, in short, any other 
direct removal of them from the system. In a therapeutic 
point of view, it is an interesting circumstance that the inter- 
nal use of iron, not merely gradually removes the bad conse- 
quences of this condition of the organism, but also effects a 
gradual augmentation in the amount of the corpuscles. 
Whether the augmentation of the corpuscles in cases of fever 



* Andral and Gavarret. 



76 PATHOLOGICAL RELATIONS OF THE BLOOD. 



is, as Andral and Gavarret believe, essentially connected with 
the disease, or whether it is merely the result of an imperfect 
system of analysis, must be decided by future investiga- 
tions. 

The quantitative determination of the blood- corpuscles requires a 
much more complicated process than that of the fibrin, and is much less 
accurate. It may be undertaken in different ways. Andral and Ga- 
varret adopt the following method : A portion of blood is allowed to 
coagulate, and the serum and clot are then separated as completely as 
possible. Both are weighed, dried on the water-bath and again weighed. 
By subtracting the latter from the former weight, we obtain the amount 
of water in the serum, and in the clot. The rest of the proceeding is 
merely numerical, being founded on the undemonstrated assumption 
that all the fluid contained in the clot was serum, and therefore con- 
tained as large an amount of solid constituents as actual serum. Hence 
we first calculate the amount of solid constituents of serum corres- 
ponding with the quantity of water separated from the clot, and subtract 
this and the fibrin (which is supposed to have been already determined) 
from the clot ; the difference is the weight of the dried corpuscles. 
The following illustration may serve to elucidate the somewhat compli- 
cated calculations requisite in this process. An old man was bled in 
consequence of strangulated inguinal hernia, and a portion of the blood 
collected in a basin of known weight. The blood weighed 280 grains. 
In the course of twelve hours, the separation into clot and serum was 
perfect. A small quantity of serum was carefully taken up with a small 
pipette, so as to include no corpuscles, and was placed in an evaporating 
basin of known weight. By deducting this weight from the given weight 
of the serum and the basin, the serum was found to weigh 95 grains. 
On drying it on the water-bath till it ceased to lose weight, the residue 
weighed 8 grains, consequently 87 grains of water had been expelled. 
The clot with the rest of the serum weighed 185 grains and after the most 
careful drying weighed 48 grains ; hence 137 grains of water were lost. 
This water is, according to the above assumption, regarded as serum, and 
is consequently associated with a corresponding amount of solid consti- 
tuents, which must be deducted from the clot. It follows from the 
above data, that 87 (the quantity of water in the serum) : 8 (the quan- 
tity of solid residue in ditto) : : 137 (the quantity of water in the clot) 
: x = 12.6. Subtracting thus from the dried clot, there remains, 
48 — 12.6 = 33.4 grains as the weight of the dried corpuscles, or 
reducing to the scale 1000 parts (280 : 33.4 : : 1000 : x), the dried 
globules amount to 119.3. 
This method of estimating the quantity of the blood- corpuscles is 



PATHOLOGICAL RELATIONS OF THE BLOOD. 77 



simple and easily performed, but does not yield very accurate results. 
It is uncertain, on account of the undemonstrated assumption, that all 
the water in the blood is associated with the same amount of solid consti- 
tuents as the water of the serum — an assumption opposed to the idea 
that a portion of the water may be combined in some other form with 
the hsematoglobulin of the blood- corpuscles, in which case the above 
calculations would no longer hold good. But besides this, it has dis- 
advantages which influence the accuracy of the results. For it is diffi- 
cult to remove the whole of the water from the portion of clot, which 
according to this process must always be tolerably large. The retained 
water increases the apparent weight of the blood- corpuscles in two ways, 
namely by its own weight, and further, by its amount of solid consti- 
tuents regarding it as serum, which in this way escapes deduction from 
the clot. Hence in proportion to the abundance of corpuscles in the 
blood, is the uncertainty of this method of analysis, in consequence of 
the increased difficulty of drying the clot. 

Another method has been proposed by Simon. He attempts a direct 
estimation of the haematoglobulin, which cannot be accomplished with 
any degree of accuracy except by an expert chemist. I, therefore, 
merely refer the reader to the description of Simon's method.* 

Instead of determining the blood- corpuscles collectively, we may esti- 
mate their individual constituents — the globulin, hsematin, and iron— 
and the ratio of each to the other. This, however, is laborious, 
difficult, and with our present resources yields only approximate 
results. 

Another method of determining the amount of blood- corpuscles in a 
direct manner has recently been proposed by Figuier.f It is founded 
on the circumstance, that on adding sulphate of soda to defibrinated 
blood, the corpuscles can be collected by filtration. He directs that 
three or four ounces of defibrinated blood be mixed with about double 
its volume of a saturated solution of sulphate of soda, and that it be 
projected on a previously weighed filter, moistened with the same 
saline solution. The serum and the saline solution pass through, while 
the blood- corpuscles remain behind. They must then be washed with 
the saline mixture, which must be removed by dipping the filter with 
the corpuscles in boiling water, which coagulates the hsematoglobulin 
while it extracts the sulphate of soda. From repeated trials I can con- 
firm this statement in all its essential points : I did not, however, always 

* Animal Chemistry, vol. i. p. 175. 

f Comptes Rendus, vol. n. p. 101 ; or Simon's Animal Chemistry, 
vol. i. p. 190. 



78 PATHOLOGICAL RELATIONS OF THE BLOOD. 



succeed in obtaining the corpuscles entirely colourless ; a proof that the 
haematin is not entirely insoluble in a solution of sulphate of soda. 

An accurate trial of these different methods of analysis instituted 
simultaneously with the same blood, and a comparison of the results 
yielded by them would be highly important. For until we are better 
informed respecting the degree of accuracy that can be attained by each 
method, any application of their results to pathology must be open to 
various objections. 

c. The amount of water in the blood may be increased or 
diminished. — The amount of water in the blood is liable to 
considerable variations, even in healthy persons, and Lecanu 
has endeavoured from numerous experiments, to deduce 
general laws on the subject. He found it less in men, more 
abundant in women ; less in vigorous persons in the bloom of 
life, larger in children and in aged and debilitated persons ; 
less in the sanguineous, larger in the lymphatic temperament. 
In 1000 parts of blood the mean quantity is 790; it is, 
however, considerably augmented in anaemia, chlorosis and 
similar conditions, in which it has been observed at 870, if 
not lower ; in cholera, on the other hand, the amount of 
water in the blood is diminished, in consequence of the 
copious liquid evacuations from the bowels. 

The estimation of the quantity of water is simple. A weighed quan- 
tity of blood must be reduced to a state of dryness on the water bath ; 
the loss is equivalent to the amount of water. As the accuracy of the 
result depends on the completeness of the drying, it is advisable to use 
a smaller quantity of blood than is recommended by Andral and 
Gavarret. 

d. The amount of albumen in the serum of the blood 
may vary. — It appears to be diminished in Bright's 
disease, and probably in other cases in which there is a con- 
siderable secretion of serous fluid from the blood (serous and 
fibrinous dropsy). In 1000 parts of healthy serum, there 
are 70 — 80 of dry albumen; but in Bright's disease the 
amount falls, according to Andral and Gavarret, as low as 
61—57. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 79 

The amount of albumen may be determined in the following manner. 
A weighed quantity of serum is neutralised with a little acetic acid, in 
order to decompose any albuminate of soda that may be present, and 
then diluted with water and boiled till v the albumen coagulates into 
flocculi. These are collected on a filter of known weight, washed with 
water, and dried on the water-bath. The accuracy of the determination 
may be increased by boiling the dried albumen in ether, which takes up 
any fat that may be present. 

e. The salts of the blood may be either increased or 
diminished. — Variations in the amount of the fixed salts 
(those, namely, left after incineration of the blood) are not 
only of common occurrence, but of considerable pathological 
importance. The salts are increased in scurvy, and it is 
very probable that this change influences the condition of 
the fibrin, hindering its coagulability, and perhaps checking 
its formation ; that it affects the blood-corpuscles by withdraw- 
ing their water, rendering them granular, and collecting them 
in heaps ; and that it thus plays an essential part in the disease 
itself. On the other hand a diminution of the salts is of 
considerable importance ; it causes a tumidity of the corpus- 
cles, favours their adherence to each other, and, according 
to Henle, tends to produce the retardation in the capillaries 
in inflammatory affections, of which we shall say more pre- 
sently. Moreover, the relative proportions of the different 
salts may change. If these observations entitle us to conjec- 
ture that we may expect important developments in this 
department of pathology, we are not yet in a condition to 
deduce general laws respecting these augmentations or dimi- 
nutions. 

The mean amount of fixed salts in 1000 parts of normal blood has 
been variously estimated by different observers, some assigning it at 
8 — 9, others 12 — 13 parts. The amount is estimated by incinerating 
the blood in a platinum crucible ; an operation requiring considerable 
time, but facilitated by frequently moistening the ashes with distilled 
water ; it must be continued till the residue forms a white or faintly 
coloured saline mass. 



80 PATHOLOGICAL RELATIONS OF THE BLOOD. 



f. The amount of urea may be increased. — In healthy 
blood it occurs in such minute quantity as scarcely to admit 
of detection. In cases where its separation by the kidneys is 
prevented or impeded, as after extirpation of those organs, or 
in Bright's disease, it increases to such an extent as to admit 
of quantitative determination. 

2. Substances may occur in the blood which do not exist 
there in a state of health. 

A. Free lactic acid. — If the blood has an acid reaction, it 
reddens litmus paper. The occurrence of free acid in the 
blood is a sign that the fluid is undergoing decomposition, 
and occurs in diseased conditions in which a tendency to 
decomposition in the fluids is suspected — in miliary fever, in 
acute rheumatism, and in puerperal fever : it is, therefore, of 
considerable pathological signification, although we are still 
not in a condition to see how the free acid acts on the blood, 
and, consequently, on the whole organism. 

Scherer found that the blood had an acid reaction in the bodies of 
persons dying from puerperal fever and phlebitis,* and declared that it 
contained free lactic acid. I have on several occasions noticed this acid 
reaction in miliary fever and in rheumatism, but only in the dead body ; 
never in blood taken by venesection. If the quantity of the acid is only 
small, the blood loses its alkaline reaction and becomes neutral ; this 
was observed by Scherer in the blood obtained by venesection, in a case 
of metritis. f In a practical point of view the acid reaction of the blood 
is a sufficient indication of the presence of the acid ; the separation of 
the lactic acid requires a difficult and complicated process. 

B. Carbonate of ammonia. — The occurrence of this sub- 
stance in the blood is also an indication of decomposition ; 
it hinders the coagulation of the fibrin, and renders the blood 
unfit to discharge its ordinary functions. This change is 
sometimes observed in well-marked cases of typhus. 

* Untersuch. p. 160, 163, 174, 230. 
t Op. cit. p. 149. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 81 



Scherer* found carbonate of ammonia in blood taken from the arm 
of a typhus patient. The means of detecting this substance are given 
in p. 67. 

c. The blood may contain a substance precipitable by 
acetic acid, resembling pyin. Schererf found a substance of 
this nature, together with free lactic acid, in the blood of a 
woman who had died from metroperitonitis. This observa- 
tion is important, because a similar, if not the identical 
matter, is of common occurrence in exudations, in pus, in 
scirrhous tumors, &c, as we shall presently see. 

To recognize this substance, the serum must be boiled in order to 
separate the albumen, and then treated with acetic acid, which throws 
down a precipitate insoluble in an excess of the reagent. 

D. The blood may contain sugar in cases of diabetes melli- 
tus. As the process for the recognition of this substance is 
intricate and difficult, I shall not attempt to describe it. 

e. The blood may contain bile-pigment which may be 
detected by the rules given in p. 63. 

In addition to these abnormal conditions, indicated by the 
art of the chemist, there are others which can only be de- 
tected by microscopic observations ; of these the most impor- 
tant are pus-corpuscles and entozoa. 

In morbid conditions of the system, pus-corpuscles in the 
blood are not of very rare occurrence. They are in some 
cases produced within the vessels, in others they enter the 
vessels from without. 

Respecting the means of detecting them, their significa- 
tion, and their mode of development, we shall have various 
occasions to speak. 

Entozoa have also been discovered in the blood, especially 



* Op. cit. p. 69. 
VOL. I. 



t Op. cit. p. 160. 
G 



82 PATHOLOGICAL RELATIONS OF THE BLOOD. 



in the lower animals. This subject will be fully discussed in 
the chapter on parasites. 

We are indebted to J. Engel # for a meritorious essay which 
has been lately published on the theory of the changes which 
the blood undergoes generally, as far as they can be revealed 
by the different pathological conditions observable after 
death. 

The following are the most important of his conclusions : 

In suppurative fermentation (Eitergdhrung) the blood loses 
its tendency to coagulate ; it is of a dirty dark red colour, 
does not become brighter on exposure to the atmosphere, and 
is very fluid. The corpse appears swollen, and presents a 
dirty appearance, being marked w r ith numerous death-spots, 
partly hypostases and partly sugillations. 

After inflammatory affections and tuberculosis, numerous 
fibrinous coagula are found in the blood, the clot is large and 
hard, and the blood more consistent than in the normal state. 
The sugillations are fewer and not so diffused, and their 
colour is less deep. 

In typhus and miliary tuberculosis the blood has a dark 
violet tint, is viscid, and exhibits no tendency to form a 
consistent clot. It is slow in reddening when exposed to 
the air, has no peculiar hypostatic tendency, but communi- 
cates to the organs, a dark violet, or reddish brown tint, 
by the firm adhesion of its colouring matter. 

In the cancerous dyscrasia, the blood is of a dark colour, 
very slight consistence, does not readily coagulate, reddens 
imperfectly, or not at all on exposure to the air, and exhibits 
a hypostatic tendency. The colour of the dead body is 
of no diagnostic importance, in consequence of the slight 
viscidity of the blood, and the consequently slight adhesive 
power of the colouring matter. 

In dropsy, the blood is not deeply coloured, and is very 

* Roser und Wunderlich's Archiv. vol. i. p. 535, &c. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 83 



fluid, but yet exhibits a tendency to the formation of small 
clots. The hypostatic appearances on the dead body are 
trifling. 

In marasmus (senilis vel prsecox) the blood is black and 
fluid, deficient in quantity, and forms no clot. It soon red- 
dens on exposure to the atmosphere, but, on account of its 
small quantity, forms no hypostases. 

In scurvy the properties of the blood closely resemble those 
in suppurative fermentation. It has, however, a deeper 
colour, and gives rise during life to the formation of petechias, 
but not to purulent depositions. Moreover, the blood in 
scurvy readily induces liquefaction of the tissues (ulcerative 
destruction), without any trace of reaction or inflammation. 
The blood of persons addicted to intoxication belongs to the 
same category. 

It is very difficult, indeed impossible, from these statements, and those 
of other observers, to draw any certain conclusions respecting the 
changes of the separate constituents of the blood, or the causes of such 
changes. In fact our whole knowledge respecting the physical and 
chemical changes of the blood is in the highest degree unsatisfactory, 
and the statements of different observers vary so widely, that it is impos- 
sible to deduce any general laws from them. It is probable that many 
may regard the preceding observations as unnecessary and aimless ; I 
had a double view in arranging them in this form. In the first place, I 
was desirous of showing how little certain information we possess on 
this subject, and how dangerous it is to base theories for whole classes 
of diseases, and proposals for their treatment, merely on individual 
observations. Secondly, I trust that they will afford a convincing proof 
of the number of different acting forces to be kept in mind, in consider- 
ing the various pathological changes of the blood. 

2. CHANGES IN THE QUANTITY OF THE BLOOD. 

The amount of blood in the human body may undergo 
changes, and may either be increased or diminished. An 
abnormal abundance constitutes plethora or hyperemia; a 
diminution, anaemia. Hyperemia or anaemia may either be 
general (in which case the whole mass of blood in the body 

G 2 



84 PATHOLOGICAL RELATIONS OF THE BLOOD. 



is increased or diminished) or it may be local. In the latter 
case, it is confined to a single organ, or to a larger or smaller 
portion of the body, while the remaining organs are either 
normal in relation to their amount of blood, or are in the 
opposite condition to the affected organ. 

Pathology has for a long time recognized the existence of 
general hypersemia or plethora as an established fact, and 
has described the symptoms by which we may detect it. 
But all these symptoms (injected countenance, full pulse, 
tendency to congestion, &c), are not infallible. We have 
no certain means of determining whether the whole mass of 
the blood is actually increased, and still less are we in a 
condition to determine it with certainty in any particular 
instance. 

The mean quantity of blood in the human body cannot be determined 
with certainty. Valentin* has pointed out a very ingenious means of 
ascertaining the quantity of blood in animals, which, if certain neces- 
sary preliminaries are determined, might give tolerably accurate results ; 
but this method cannot be applied to man. In fact, all the means 
hitherto proposed for determining the amount of blood in the human 
body have been very unsatisfactory. We are usually contented with 
estimating the amount of blood from the degree of redness in the diffe- 
rent parts of the dead body, from the contents of the large vessels, and 
from the blood that escapes on making incisions in various parts. These 
means are important, as showing comparatively the amount of blood 
in the different parts of the body, but they are of little or no value in 
enabling us to ascertain even approximately the whole amount of blood 
in the body. To clear up this point, I propose another method, which 
although difficult and tedious, would yet give far more accurate results. 
By carefully washing out the vessels of a body by injection with pure 
water, all the hsematoglobulin contained in those vessels may be obtained, 
and after purification can be estimated quantitatively. Any conclusion 
respecting the whole quantity of blood deduced from the amount of 
hsematoglobulin is doubtless always uncertain, in consequence of the 
varying proportions in which that constituent may be present in the 



* Repertorium, vol. in. p. 281, &c. ; or, Physiologie, vol. i. 
p. 490. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 85 

blood. In cases, however, when it is possible to institute venesection 
shortly before death, we might ascertain by the processes already given, 
the proportions in which the corpuscles occur, and then after death calcu- 
late the whole amount of blood with tolerable certainty. Laborious to an 
extreme degree as these investigations are, they are essential for the per- 
fection of our knowledge of the blood. Until by such, or similar experi- 
ments, general plethora becomes better understood than it now is, all that 
has been stated regarding it must be considered as merely hypothetical. 

There is a close parallelism between general anaemia and 
general plethora. It is certainly an undoubted fact, that by 
loss of blood the quantity of that fluid in the body is dimi- 
nished, and that, for instance, a man directly after a copious 
venesection contains less blood than in the normal state. The 
loss is probably rapidly made up by the absorption of fresh 
matter, especially of water, so that the amount of blood may 
become the same as before. It is true that the blood 
possesses a different composition than it previously did, con- 
taining fewer corpuscles, and more water and albumen, but 
this condition should not be termed anaemia, but, as has been 
very properly suggested by Simon, spanaemia;* and the 
symptoms in the dead body, dependant on this condition, are 
those commonly associated with the occurrence of anaemia. 
General paleness, deficiency of red clots in the vessels, and 
the escape of but little red blood, on making incisions into 
the different organs, are not always to be regarded as signs of 
anaemia, since they are equally likely to occur when spanaemia 
is present. 

Local hyperaemia, as it occurs in the dead body, may 
have its seat in the veins or in the capillaries, sometimes 
occurring simultaneously in both sets of vessels. 

Venous hyperaemia may be detected with the naked eye, or 
if only the smaller veins are affected, with a lens. The veins 
usually present a continuous ramifying appearance, are more 
distended than usual, and contain a blue, violet or reddish 



* From or7ravo£, poor. 



86 



PATHOLOGICAL RELATIONS OF THE BLOOD. 



brown, or occasionally blackish blood, which escapes on 
making an incision. On cutting into the part affected, 
the section reveals numerous isolated blood-spots. Venous 
hyperemia is usually accompanied by an effusion of dropsi- 
cal fluid from the distended veins ; in the dead body, this may, 
however, be absent, or at any rate may escape observation, 
since local hyperemia is very limited, and exists only for a short 
time, and the effused serous fluid may have been resorbed 
by the lymphatics. The causes of this hyperemia are partly 
mechanical — as obstruction of the venous trunks, stoppage of 
the heart's action, &c, and partly dynamic — as dilatation of 
the venous walls through the influence of the nerves.* 

Hyperemia of the capillaries. — The capillaries of diffe- 
rent parts of the body frequently appear to be dilated to a 
greater or less degree, and to be over-filled with blood. In 
the lesser degrees of hyperemia, the diameter of the capilla- 
ries increases by one half; in the more highly developed cases, 
the diameter is sometimes double, or even treble the ordinary 
length, and then the vessels not unfrequently become ruptured. 
The blood so completely fills up the whole lumen of the ves- 
sels, that the interstices at their border, which in the normal 
state are free from blood-corpuscles, disappear. The blood- 
corpuscles themselves are much more closely pressed on each 
other than is usual, so as to prevent them from being recog- 
nized individually, and the whole of the blood forms an appa- 
rently homogeneous and coagulated mass ; but on removing 
the blood from the vessels by pressure, &c, the corpuscles 
again become separated, and the fluid assumes its normal 
appearance. 

The part affected by hyperemia is redder than usual. This 
abnormal redness may be either general or local, according to 
the extent of the hyperemia ; and decreases gradually as it 
approaches the unaffected parts. Under the microscope, it is 
observed that the redness is not uniformly distributed over the 



* See p. 42. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 



87 



whole of the affected part, but that it follows the course of 
the capillaries, while the interstices remain colourless. # On 
cutting into the hypersemic organ, a more than ordinary 
quantity of blood escapes, in which the corpuscles are normal, 
or only slightly modified. The affected part is . also denser 
than usual; the consistence is either normal or apparently 
softened; it is never increased, unless, in addition to the 
hyperaemia, there is also a deposition of coagulated fibrin. 

The above relations are sufficient to render the diagnosis 
a matter of certainty. It can only be confounded with 
extravasation of blood, and with infiltration of dissolved 
haematin. The points serving to distinguish between them 
will be found in our remarks on these pathological con- 
ditions. 

Causes, mode of formation, and termination. — Hyperaemia 
of the capillary vessels is dependant on two forces (momenten) 
— on a dilatation of the capillaries, and on the accumulation (and 
retardation) of the blood-corpuscles in them. The causes of 
these two forces, their mutual dependance, and the manner 
in which the whole process is conducted, belong to a depart- 
ment of pathology in which our knowledge is by no means 
accurate. To follow out this subject would lead us into the 
obscure domain of nervous pathology, and the physiology 
of tissues ; we shall confine our remarks at present to those 
points which more especially fall within the range of patholo 
gical anatomy. 

In many cases capillary hyperaemia is undoubtedly depen- 
dant on the nervous system ; this, from whatever cause it is 
induced, gives rise to dilatation of the capillaries and relaxa- 
tion of their walls : the dilated capillaries receive, on purely 
mechanical grounds, more blood than they previously did ; and 
a capillary which in its normal condition could admit of the 
passage of only a single row of corpuscles, may now admit of 
two or three. At the same time an excess of plasma escapes 



* See pi. ii. fig. 1, b. 



88 PATHOLOGICAL RELATIONS OF THE BLOOD. 

through the attenuated walls of the capillaries. The part 
affected contains an excess of blood-corpuscles, and hence 
appears reddened. This is the condition which is known in 
pathology, as congestion ; it frequently occurs in the living 
body in external parts, as in the face, the eye, or the skin ; 
it is, however, more rarely observed in the dead body, since 
it is seldom a cause of death. Here there is no stoppage 
of the blood-corpuscles, the whole process being dependant 
simply on dilatation of the capillaries. If the blood-corpuscles 
become impeded, the process cannot be referred to mere dila- 
tation. Henle # has made a very ingenious attempt to refer 
the stagnation of the corpuscles to mechanical and chemical 
causes. He supposes that in consequence of the exudation 
arising from the attenuation of the capillary walls, the plasma 
becomes modified, containing proportionally more albumen 
and fibrin, but a smaller amount of salts than in the normal 
condition. This chemical change in the plasma communi- 
cates to the corpuscles a tendency to adhere, and this adhe- 
rence mechanically induces stagnation. Plausible and ingenious 
as is this theory of the stagnation of the blood, it must only 
be regarded as a mere hypothesis, against which weighty 
arguments may be adduced ; and we must confess that our 
knowledge is still uncertain respecting the true reasons of this 
phenomenon. 

As that form of capillary hyperemia, in which there is no 
stagnation of the corpuscles is termed congestion, so the 
higher degree — where they stagnate, and the local circulation is 
arrested — is termed stasis. On examining these conditions in 
the dead body, we find no difference between them. It is like- 
wise perfectly indifferent, whether the process is accompanied 
with symptoms of nervous irritation (true inflammation) or 
with depression of the central nervous system, (hypostatic 
inflammation, passive hyperemia). The phenomena of 

* Henle u. Pfeufer, Zeitschrift fur rat. Medicin, vol. u. No. i. 
p. 130, &c. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 89 



dilatation of the capillaries, of the aggregation of blood- 
corpuscles in them, and of the effusion of serous or fibrinous 
fluid from them, are in both cases the same, and the patho- 
logist is unable to draw any certain distinction between 
them. 

The further course, and the combinations of local hyper- 
emia are very numerous, for it is usually associated with 
the effusion of serous or fibrinous fluid, and frequently with 
rupture of the vessels and extravasation of blood. Its termi- 
nations are : 1 , disappearance of the hyperemia by the disper- 
sion of the impeded corpuscles, and the re-contraction of the 
vessels ; 2, the occurrence of decomposition of the blood, in 
which case the hematin dissolves in the serum ; 3, or of gan- 
grene, in which case the whole of the blood undergoes a 
chemical change. Of this we shall speak presently. 

As we have local hyperemia, so likewise is there local 
anemia. It may be recognized by the affected part being 
paler than usual, and by the effusion of very little blood on 
making an incision. Its causes are: 1, a constriction or 
occlusion of the arteries supplying the part ; or 2, a contrac- 
tion of the capillaries dependant on the nervous system, as, 
for instance, in sudden pallor of the cheeks, &c. 

3. EXTRAVASATION OF BLOOD. 

It frequently happens that, in consequence of laceration of 
the vessels, the blood escapes from them and is effused in 
the cavities of the body or in the parenchyma of the organs, 
between the histologic elements. The process is termed 
hemorrhage, and the blood itself is said to be extravasated. 

The effused blood may either coagulate or remain 
fluid. Generally, we only find it coagulated when it has been 
effused in large quantity, — as after wounds, in severe apo- 
plectic attacks, and in pulmonary and bronchial hemorrhage. 
The coagulation, as in ordinary cases, depends on the solidi- 
fication of the fibrin, and the clot is composed of that con- 



90 PATHOLOGICAL RELATIONS OF THE BLOOD. 



stituent and the corpuscles enclosed in its meshes. Blood 
effused into the intestinal canal (in hsematemesis and meleena) 
coagulates in a peculiar manner; the fibrin remains fluid 
while the albumen of the plasma becomes coagulated by the 
free acid of the gastric juice, and encloses the blood-corpuscles. 
Moreover, this acid converts the red colour of the blood into 
a blackish brown tint. The process may be imitated artifi- 
cially by adding hydrochloric or sulphuric acid to defibrinated 
blood. In other cases we find the extravasated blood remain 
fluid, especially when it is effused in small quantity. On 
removing this fluid blood from the body, it usually coagulates 
spontaneously after a short time ; and on examining it under 
the microscope, the corpuscles are found to be normal or only 
slightly modified ; hence in its essential characters it resembles 
normal blood. 

Extravasations of blood may be divided into : Firstly, those 
of the capillary system, in which the effused blood either 
forms small points scarcely visible to the naked eye, or is 
uniformly distributed through the parenchyma of the affected 
part, which thus becomes either uniformly reddened, or is else 
merely covered with red specks. In this case the blood 
proceeds from the smaller vessels, and this condition, or 
an alternation of it with capillary hyperemia, is often noticed. 
Secondly, effusions of a large volume of blood. The effused 
blood then forms large masses, which may be easily recognised 
and distinguished from the surrounding parts. In capillary 
extravasation, the blood is most commonly fluid, in the 
other form it is generally coagulated. 

The quantity of effused blood is extremely variable ; it may 
be only a few drops or may amount to several pounds. 

Causes, formation, and ultimate fate of extravasated 
blood. — Extravasated blood always proceeds from the vessels, 
and results from their laceration. The view, that at least 
some of these effusions of blood may occur without any injury 
of the vessels, by a mere transudation of blood through the 
attenuated vascular walls (diapedesis) is altogether untenable, 



PATHOLOGICAL RELATIONS OF THE BLOOD. 91 

although some even of our recent authors (Carswell amongst 
others) # still support it. The walls of the blood-vessels — even 
of the smallest capillaries — are so impervious, that it is impos- 
sible for such large particles as the blood-corpuscles to pass 
through them in an uninjured condition. Moreover, the smaller 
vessels may be so readily lacerated by numerous internal 
causes, without any outward injury, that there is no difficulty 
on the point, and the fact that those sanguineous effusions 
which occur in the normal state — as the menstrual discharge — 
are dependant on an injured condition of the vessels, is con- 
firmatory of it. In many cases in which the blood is dis- 
charged from larger vessels, we may easily detect the seat of the 
injury, and consequently the source of the haemorrhage ; if we 
are not always so fortunate in haemorrhage from the capilla- 
ries, it is owing to the imperfection of our diagnostic aids, 
not to the absence of a lacerated vessel. 

The causes giving rise to laceration of the vessels, and 
consequent effusion of blood are very numerous ; many of 
them are external, and mechanical or chemical in their nature : 
as wounds with cutting or stabbing instruments, bruises, blows 
and concussions ; occasionally the vessels are injured by caus- 
tic applications, as for instance, caustic potash. The manner 
in which these different influences work is too obvious to 
demand any explanation ; but, moreover, there are certain 
morbid processes within the body that frequently injure 
the vessels, and cause the extravasation of blood, as 
for instance, violent coughing or vomiting, mortifica- 
tion, suppuration, or softening of tumours, destroying the 
organic tissues, and hence injuring the continuity of the 
vessels in a manner presently to be described. Another very 
frequent internal cause of rupture of the vessels is a disturbed 
state of the circulation. When, in any part of the body or 
from any cause, the circulation is either temporarily or perma- 



* Patholog. Anatomy, fasc. 6. Hemorrhage. 



92 PATHOLOGICAL RELATIONS OF THE BLOOD. 

nently impeded, the pressure of the blood in the vessels of the 
adjacent parts is increased, and their laceration often results. 
Hence all the forms of hyperemia, described in the former 
section, are frequently associated with extravasation of blood. 
It is observed in obstruction of the veins, in stoppage of the 
heart's action, in stagnation in the capillaries, and, indeed, 
in almost every case of inflammation. Hence it is that extra- 
vasation of blood is so frequently combined with hyperemia, 
with the effusion of serous or fibrinous fluids, and with sup- 
puration. Moreover, pathological changes in the walls of the 
vessels themselves frequently give rise to laceration, and it 
has been especially noticed that the arteries are more easily 
lacerated than usual under the ordinary pressure of the 
blood, when their walls have become softened by atheromatous 
deposits, or have become brittle by the deposition of earthy 
matter. 

Amongst the causes of extravasation, many writers place 
certain changes in the blood itself, especially those that occur 
in ordinary and land scurvy, and in the higher degrees of 
putrid fever and typhus. But we must clearly distinguish 
between the extravasation of actual blood containing cor- 
puscles, and the infiltration of dissolved hsematin which 
transudes through the uninjured walls of the vessels, and 
will be considered in the next section. This dissolved 
condition of the hsematin is entirely dependant on a decom- 
posed state of the blood. In typhus, petechial and putrid 
fever, &c, the extravasation of true blood is, however, very 
frequent, but is always dependant on laceration of the vessels ; 
and in producing this laceration a change in the composition of 
the blood can only act a very secondary part. It can at most 
only act through a series of means, by favouring congestion 
and stagnation of the blood. On these points, however, we 
know very little. 

The further course of extravasated blood resembles in all 
essential points that of a fibrinous fluid. Firstly, it may 
either be resorbed and thus disappear ; or secondly, it may 



PATHOLOGICAL RELATIONS OF THE BLOOD. 93 

act as a cytoblastema and become organized. A perfect 
resorption is probably only possible while the blood remains 
fluid. This fluid undergoes various modifications in its pro- 
perties, corresponding doubtless with chemical changes with 
which we are at present only imperfectly acquainted. When 
blood is extravasated in a part where its changes can be 
traced with the eye, as for instance, under the epidermis, it 
gradually undergoes progressive changes of colour ; it passes 
from a dark red into a blue, then into a brown, and lastly 
into a yellow colour, before it entirely disappears. The 
causes of these changes are unknown. Sometimes they do 
not occur; blood which was effused in the conjunctiva 
from straining during a severe cough, gradually disap- 
peared without any change of colour, the last traces exhi- 
biting the tint of normal blood. Scherer* has carefully 
examined the changes which blood, extravasated in conse- 
quence of a blow on the upper part of the thigh, underwent 
as long as it remained in the body. After a few days, it lost 
its power of coagulating, and contained no more fibrin. The 
blood-corpuscles were still observable, but were spherical and 
swollen ; and the blood itself contained more water, and less 
solid constituents than in the normal state. Three days later, 
the corpuscles disappeared, the blood was much more liquid, 
and contained a few pus-corpuscles, and in the course of a 
few days it was entirely converted into pus. 

When coagula of blood become organized, as in certain 
apopletic cases, the changes are much more complicated. 
The clot is usually found after some time to consist of two 
distinct substances, an inner one, which is soft and forms a 
reddish brown mass (changed blood-corpuscles), and an outer 
one consisting of firmer layers, which are white, or at any rate 
less red than the inner mass, and present a granular 
amorphous appearance under the microscope. This difference 
between the outer and inner portions may be referred to two 



* Unters. p. 194. 



94 PATHOLOGICAL RELATIONS OF THE BLOOD. 

distinct causes : either the coagulum, in consequence of the 
irritation which it produces, gives rise to inflammation of the 
surrounding parts, and to the exudation of fibrinous fluid which 
deposits itself in a coagulated form around the original clot ; 
in which case the outer white layers are new formations, alto- 
gether independent of the original clot : or the hsematin in 
the outer layers of the coagulum, to which the fluids are readily 
accessible, may be for the most part absorbed, and the dif- 
ference in colour between the outer and inner layers thus ac- 
counted for. In many cases it is probable that both these 
causes are in operation ; I think, however, that we may con- 
clude, from numerous observations, that every considerable 
extravasation of blood causes an effusion of fibrinous fluid 
around it, and is, therefore, generally combined with fibri- 
nous dropsy. In its further course of development, the clot 
appears to be influenced by the general laws, which form 
the subject of our next chapter. The most distinct products 
may be evolved from the blood ; pathologically, pus, granular 
cells, melanosis, &c. ; normally, cellular and fibrous tissues, 
vessels, &c. ; also concretions. 

Extravasated blood undergoes a peculiar change in gan- 
grene. It becomes converted into blackish brown clots with 
a cadaverous odour, and frequently covered with black gra- 
nules in which no blood-corpuscles can be recognised. 

Further information on this subject will be found in our section on 
gangrene. See also pi. ix. Fig. x. 

Consequences of extravasated blood, anatomical relations 
of the surrounding parts, and frequency of its occurrence. 
The consequences of extravasation of blood are partly gene- 
ral and partly local. The general are chiefly dependant on 
the amount of blood which is thus removed from the vascu- 
lar system, and is consequently prevented from discharging its 
ordinary functions in the body ; when the amount is small, 
they are very trifling, but if it is large, there may be much 
debility, or even death induced. The local consequences are 



PATHOLOGICAL RELATIONS OF THE BLOOD. 



95 



dependant on the action of the effused blood on the surround- 
ing parts, (chiefly by the pressure and mechanical influences 
exerted by it) ; also on the quantity of the extravasation, and 
on the functions and importance of the organ in which it has 
taken place. Thus, considerable effusion of blood in the brain 
produces apoplexy, with its consequences ; in the lungs and 
bronchi it fills the air cells, and checks respiration ; in the 
pleura it compresses the lungs, and in that way impedes res- 
piration ; in the urinary bladder, by coagulating in the urethra, 
it gives rise to a mechanical stoppage, and retention of urine 
with its consequences ensues. Finally, amongst the evils 
arising from extravasated blood, we may reckon softening, 
inflammation, suppuration, ulceration, and gangrenous destruc- 
tion of the affected part. 

The anatomical relations of the surrounding parts differ 
extremely in different cases. When hyperemia and stagna- 
tion are the causes of extravasation, the surrounding parts 
appear hyperaemic, even in the dead body; in other cases 
where the effusion has been very copious, the whole body 
appears pale and bloodless. 

The extravasation of blood is a very frequent occurrence, 
and may take place in almost any organ containing blood- 
vessels ; in the lungs constituting haemoptysis, in the brain 
apoplexy, in the stomach and intestinal canal haematemesis 
and melaena ; it is likewise not uncommon in the kidneys, 
urinary bladder, and uterus. The particulars of these forms 
of haemorrhage are further noticed in the chapters on these dif- 
ferent organs. 

Diagnosis of extravasated blood. — Effused blood may be 
generally detected with the naked eye ; if the quantity is very 
small, it may, however, be requisite to have recourse to the 
microscope. The only appearances with which it can possibly 
be confounded are hyperaemia of the capillaries and infiltration 
of haematin. The distinction between extravasation of blood 
and hyperaemia of the capillaries is not always obvious, and the 



96 PATHOLOGICAL RELATIONS OF THE BLOOD. 



difficulty is increased by their frequently occurring together. 
We may be assured that extravasation has occurred when the 
redness of a part is not uniform, but distributed in patches, 
and further, when the specks of blood which we can detect, 
either with the microscope or the unaided eye, have a larger 
diameter than the vessels of that part, even when dilated to 
the utmost. Sometimes other circumstances contribute to 
strengthen the diagnosis ; thus, for instance, there would be 
great probability in the assumption that blood was extrava- 
sated in the lungs, if during life the sputa were observed to 
contain numerous blood-corpuscles, as occurs in pneumonia, 
or when in the dead body the bronchi were found to contain 
bloody mucus. Coagulated blood in the ureters, and bloody 
urine lead to the inference that there has been extravasation in 
the kidneys. Fortunately in these cases where the diagnosis 
between these two conditions is not easy, its accurate esta- 
blishment is of no great value, for each is intimately combined 
with and keeps up the other, and the extravasation is most 
commonly produced by hyperemia and stagnation of blood. 

The difference between the extravasation of blood and the infiltration 
of haematin is explained in the following section. 

Blood effused into the stomach and intestinal canal, and either 
found there on dissection, or discharged by the mouth or the 
rectum, has, however, a different character. Instead of 
being red it is of a brownish black colour, and of the consis- 
tence of tar, or else flocculent and resembling coffee grounds. 
Under the microscope there are observed patches of an irre- 
gular form and size, but of a deep reddish brown colour, 
like the blood modified by gangrene, # and in which no blood- 
corpuscles can be observed. This appearance is caused by 
the blood coming in contact with the acid of the gastric juice, 



* See pi. ix. fig. 10. 



PATHOLOGICAL RELATIONS OF THE BLOOD. 



97 



and other intestinal fluids, by which its albumen becomes 
coagulated. When it is found in the stomach, or has been 
discharged by vomiting, it is liable to be mistaken for bile. 
The diagnosis is easily effected by the addition of nitric acid, 
which changes the colour of bile from a dark into a clear 
green, then into a blue, violet, purple, and, finally, a pale red ; 
while the blackish-brown blood, in the absence of bile, does 
not undergo these modifications. 

4. SOLUTION OF HjEMATIN AND SATURATION OF THE TISSUES WITH IT. 

When on making a dissection we observe the various 
organs of a blood-red colour, we sometimes hastily conclude 
that there is either extravasation of blood, or hyperemia, 
whereas a more careful examination would show that the red 
colour was due to the saturation of the tissues with serum 
containing hae matin in solution. Hsematin seldom becomes 
dissolved during life, but often after death. We sometimes 
observe it during life in gangrene, and in putrid and petechial 
fevers. In these cases the blood obviously undergoes a che- 
mical change, which causes the hsematin to dissolve in the 
serum. The nature of these changes is not accurately known ; 
they probably depend on various causes, such as the occurrence 
of free lactic acid, or of carbonate of ammonia in the blood, 
and possibly on a great diminution of the salts. In gangrene 
there is not unfrequently observed a clear red, or else a turbid 
brownish fluid in vesicles under the epidermis, constituting 
gangrenous ichor. This is merely serum tinged with dis- 
solved hasmatin ; the brown colour occasionally noticed is pro- 
bably dependant on a modification of the hsematin, produced 
either by an acid or by ammonia, similar to that which occurs 
in melsena. In those cases in which the hsematin becomes 
dissolved during life, the whole mass of the blood is probably 
not affected, but only a portion, which has either stagnated in 
or escaped from the vessels. # This change is, however, of 



* See the description of fig. 10 in pi. ix. 
VOL. I. H 



98 PATHOLOGICAL RELATIONS OF THE BLOOD. 



much more frequent occurrence after death than during life, 
and we may conclude that when it occurs very soon after 
death, the blood during life must have had a tendency towards 
decomposition. In due time it invariably occurs in the dead 
body, as a consequence of putrefaction ; ammonia and other 
products being formed, which dissolve the liBematin. 

This condition should be carefully studied, for the red 
colour dependant on it, (which is very frequently observed in 
the inner surface of the heart and larger arteries, and 
likewise occurs in the bronchi and other parts,) is very 
often mistaken in dissection for the redness of inflammation. 
This redness is for the most part less intense than that from 
hyperemia or extravasated blood, and is more uniformly distri- 
buted, more subdued, and rather of a purple than a blood- 
red colour. The microscope will always settle the point ; it 
will show that the capillaries in the affected part are not 
gorged with blood as in hyperemia, and that there are no 
masses of blood-corpuscles as in extravasation. The latter 
are altogether absent, and, under the microscope, the part 
appears of an uniformly red colour, but pale in proportion 
to the magnifying power. 



PATHOLOGICAL EPIGENESES. 



99 



CHAPTER IV. 

PATHOLOGICAL EPIGENESES.* 

In the primary formation of the body, and subsequently in 
its nutrition, new formations (elementary particles and tissues) 
arise, interpolated as it were between those already existing. 
A somewhat similar process is of frequent occurrence in 
pathological formations ; indeed, so frequent are these mor- 
bid epigeneses, that the greater number of the changes 
which pathological anatomy can demonstrate after death may 
be arranged under this head. At the same time, they are so 
various, and the relations of their formation, development, 
and termination in individual cases so different, (two or more 
epigeneses being frequently associated and combined,) that a 
satisfactory description of these conditions, including a clear 
arrangement and separation of the individual elementary phe- 
nomena is a task of the greatest difficulty. 

In order not to lose ourselves in the details connected with 
this extensive department of our science, and at the same time 
to acquire a clear view of these various relations, we shall 
attempt to work out, as far as possible, the general laws 
followed by pathological formations in their development. 
These laws are very closely allied with those which direct 
the development and formation of tissues in the normal state • 
indeed, in many cases, no definite line can be drawn between 
normal and abnormal formations. 

* Neubildungen, literally, new formations. 

H 2 



100 



PATHOLOGICAL EPIGENESES. 



It cannot be expected in pathological anatomy that the nltimate 
causes of all morbid changes in the organism should be noticed, 
any more than that all the symptoms should be described ; which gene- 
rally accompany those changes. On the other hand, it is a most im- 
portant point to distinguish, as far as our opportunity for observation 
will allow us, the origin, development and gradual formation of these 
changes ; further, we should investigate the general laws of their forma- 
tion and development as far as this can be done by cautious conclusions 
from undoubted observations, and we should compare these laws with 
those which apply to the normal development of the whole organism, 
and of its individual parts. 

Pathological epigeneses naturally divide themselves into 
wo groups, the organised and the unorganised. 
The distinction between these groups is a double one. 

1 . There is a morphologic difference. — Organized bodies 
exhibit the same perfect form and internal organization 
throughout as in their separate parts, and as soon as they 
become parts of the organism. Unorganized bodies are devoid 
of organization, the highest and most perfect form they can 
assume being that of a crystal. 

2. There is a genetic difference. — Unorganized formations 
are always produced in accordance with the laws of pure 
chemistry, while organized formations follow the develop- 
mental laws of organic life. 

If even in perfectly normal formations, the difficulty in 
denning the limit between vital organization and mere che- 
mistry is considerable, in pathological formations it is much 
increased, for each may be combined with, and indeed merge 
into the other, so that in individual cases, it is not always 
easy to determine to which group a formation belongs. This 
does not, however, hinder us from regarding the two groups 
as representing opposite types. In their chemical composi- 
tions there are no essential differences, except that the orga- 
nized formations consist, for the most part, of the substances 
known in chemistry as compound radicals ; while the unorga- 
nized consist in part of inorganic matters, although compound 
radicals frequently also enter into their composition, and hence 



PATHOLOGICAL EPIGENESES. 



101 



the terms organic and organized are not altogether synony- 
mous in relation to morbid formations. 

Like every thing else in nature, pathological growths re- 
quire a material for their formation — a matter from which they 
may be produced. To this which may be either fluid or solid, 
and may vary extremely in its chemical composition, we 
apply the general terms plasma, or formative matter. 

It is a necessary character of this plasma to be amorphous ; 
it must neither be crystalline, nor have a definite organic 
form. An already formed structure can only assume that 
function by throwing off its shape and becoming again 
structureless. 

A plasma may act as formative material either for organized 
or unorganized products, or for both at the same time. The 
plasma for unorganized formations, which is usually an 
aqueous solution, from which deposits are produced or crys- 
tals formed in accordance with chemical laws, we shall name 
a mother-liquid; the matter giving rise to organized for- 
mations which are chiefly produced by the formation of 
cells, we shall term a cytoblastema* or, for brevity, a 
blastema ; and lastly a plasma, from which organized and 
unorganized products are developed, will be designated as a 
mixed plasma. 

The manner in which pathological formations are produced 
from a mother-liquid is essentially different from that in 
which they are produced from a cytoblastema. The former 
being the most simple will be first considered. 

Almost any fluid in the body may act as a mother-liquid 
for pathological formations, if a portion of the dissolved un- 
organized or organized matters assumes an insoluble condi- 
tion and separates as a precipitate. The conditions under 
which this phenomenon ensues are very numerous ; but, as far 
as yet known, are influenced simply by chemical laws. A 
deposition frequently occurs from too concentrated a condi- 



* From kvtos, a cell ; and ftXaarn^, growth. 



102 



PATHOLOGICAL EPIGENESES. 



tion of the mother-liquid ; substances thus assuming a solid 
form, from the absence of a sufficient quantity of water to 
retain them in solution. Such a concentration may occur 
when a thin fluid, almost saturated with substances difficult of 
solution, is placed in contact with an animal membrane, on 
the other side of which is a fluid deficient in water ; under 
these circumstances, it follows from the laws of endosmosis 
that the original fluid will lose a portion of its water: or 
when a fluid parts with water by evaporation from a free sur- 
face, as for instance in the nasal cavities. There is also 
another very obvious cause for the production of deposits, 
depending on the circumstance of the solvent power of acids 
and alkalies. For instance, human urine in the normal state 
is acid. The free acid is here the condition by which the 
earthy phosphates are retained in solution. If for any reason 
the urine, either in the bladder or in the pelvis of the kidney, 
becomes alkaline (from the alkaline serum of the blood 
entering it, or from the decomposition of urea into carbonate 
of ammonia) the earthy phosphates can no longer be retained 
in solution, and become deposited in an insoluble state. 
Again, an excess of free acid in the urine decomposes the 
urates, and if the secretion is very deficient in water, the 
liberated uric acid which is not so soluble as its salts, no 
longer remains in a state of solution. Most of the fluids of 
the human body contain phosphate of magnesia — a salt of 
considerable solubility : on coming in contact with ammonia, 
a very insoluble compound — ammoniaco-magnesian phosphate 
— is at once produced ; hence, when the body undergoes putre- 
faction, and ammonia is set free, almost all the tissues are 
bestrewed with crystals of this salt. It is true that the causes 
for the formation of unorganized depositions are not always so 
simple and clear as in the above cases, as will be seen on re- 
ferring to the section on the concretions, where the matter is 
more fully discussed. It is sufficient in the present place to 
have shown that all the pathological depositions of whose for- 
mation we have any clear idea, are formed in strict accor- 



PATHOLOGICAL EPIGENESES. 



103 



dance with the laws of chemistry, in a manner that can fre- 
quently be imitated in the laboratory. 

These products may vary in form ; sometimes they occur 
in a very minute granular state, sometimes in indefinite crys- 
talline masses, and sometimes in perfect crystals, which are 
usually so small that their form cannot be recognized by the 
unaided eye. These varieties depend, as in ordinary chemical 
processes, on the rapidity or slowness of the separation, and 
on the crystallizing or non-crystallizing tendency of the sub- 
stances. 

In chemical composition they vary in accordance with 
the place of their formation, and the properties of the 
fluid which acted as the mother-liquid. There are two 
classes of morbid products which we must distinguish 
from each other, namely, those which are formed in fluid 
secretions, possessing specific chemical constituents, and 
such as occur in the parenchyma of organs, in the cellular 
tissue, &c. The latter closely resemble each other in 
chemical composition, from whatever part of the body they 
are obtained ; they usually consist for the most part of 
earthy phosphates and carbonates, (lime and magnesia,) and 
their ordinary mother-liquid is the exuded plasma of the 
blood, which may be regarded in the light of a mixed 
plasma, that is, it usually gives origin to unorganized as 
well as to organized morbid products, so that the process is 
only in part influenced by the laws of chemistry. A few of 
the depositions occurring in the parenchyma form an ex- 
ception to this general law ; for instance, gouty concre- 
tions, which consist of urate of soda. The depositions, on 
the other hand, which are formed in the fluid secretions, 
have a varied chemical composition corresponding with 
differences in the mother-liquid from which they are pro- 
duced. Earthy phosphates and carbonates occur also here, 
but many other matters may likewise be present, as for in- 
stance, the fatty acids, cholesterin, margarin, bile-pigment, 
uric and oxalic acids, uric oxide, cystin, &c. 



104 



PATHOLOGICAL EPIGENESES. 



The production of the above morbid products is riot always 
accomplished by means of a finely granular or crystalline 
precipitate : as a general rule, each simple primary form yields 
compound secondary forms : the particles of the deposit adhere 
together by new depositions — by mucus or some other means 
of connexion — and form larger masses visible to the naked eye, 
and either soft or firm, according to the nature of their consti- 
tuents. These are named concretions, concrements, or calculi ; 
they occur for the most part in the fluid secretions, in cavi- 
ties or canals, and may be either free or connected with the 
adjacent walls. Their form is usually irregular, being some- 
times dependant on that of the cavity in which the concretion 
was produced, and sometimes on the simultaneous presence 
of several concretions rubbing against and so flattening each 
other, and thus often producing a shape almost as regular as 
that of a perfect crystal. They are frequently composed of con- 
centric layers deposited round a nucleus. Their fracture is 
occasionally crystalline, as in many urinary calculi, and in gall- 
stones consisting of cholesterin, and it is but rarely that a definite 
external form determines the corresponding internal appear- 
ance, which, however, appears to be the case in prostatic con- 
cretions. In other cases these concretions instead of being free 
are connected with the surrounding tissues, often so intimately 
as not to admit of separation by mechanical means : this is 
especially the case with concretions in the cellular tissue, and 
in the parenchyma of organs. Inserting themselves between 
organized parts, the histological elements are compressed to 
the utmost, and their physical properties as well as those of 
the whole organ are changed. Such depositions are termed 
ossifications, although hardness is the only character they have 
in common with bone, and, histologically, they differ most 
obviously from recently formed osseous tissue. Occasionally 
such depositions surround organized parts, forming incrustations 
and filling up their cavities, so as to exhibit a very regular 
and, at first sight, extremely surprising form. Thus the 
epithelium cells occasionally present in the urine become 



PATHOLOGICAL EPIGENESES. 



105 



incrusted by urinary sediments, and probably the regular 
spherical concretions of lime found in the choroid plexus 
are formed in a similar way by incrustation of the cells. # 
Intimate as the connexion between these depositions and 
organized forms sometimes appears to be, the adhesion is 
never chemical, but merely mechanical, and on removing the 
unorganized structures, either mechanically or chemically, 
the organized parts stand forth in their original normal 
form. 

It is deserving of especial mention, that the production of 
many unorganized formations is dependant on the develop- 
ment of a new secreting organ, previously created by a morbid 
process. In illustration, we may mention the deposition of 
crystallized cholesterin in encysted tumours, especially in that 
form termed by Cruveilhier the laminated nacreous tumor, 
where the deposition is so abundant, that the whole con- 
tents form a connected and often tolerably firm crystalline 
mass. 

ON THE DEVELOPMENT OF ORGANIZED PATHOLOGICAL FORMATIONS. 

The development of organized morbid tissues is depen- 
dant on laws differing essentially from the chemical laws 
already considered. The difference is obvious even in the 
formative material. It is not every mother-liquid that 
can act as a cytoblastema for organized products. The 
cytoblastema is usually fluid ; it may, however, be solid, but 
in this case it must of necessity be amorphous, that is, it 
must not exhibit either a definite organized appearance, or 
crystallization. The only solid cytoblastema which has yet 
been noticed in relation to morbid products is coagulated 
fibrin in its amorphous condition and permeated with water, 
in the state, for instance, in which it occurs in inflammatory 
exudations. But even this blastema was originally fluid, and 



* Compare Henle's Allgem. Anatomie, p. 10. 



106 



PATHOLOGICAL EPIGENESES. 



only assumed the solid form on the coagulation of the fibrin. 
It is possible, although it has not yet been observed, that 
other protein-compounds — albumen, casein, or globulin — 
may act when coagulated as cytoblastemata. In the pro- 
duction of morbid formations from mother-liquids, the 
plasma seems never to occur in a solid state : if in the 
department of unorganized nature, as in chemistry or mine- 
ralogy, a crystalline formation can take place in a par- 
tially or entirely solid amorphous substance, as for instance, 
in iron, sugar, silica, &c, nothing similar has yet been 
observed in the human body. 

As fibrin in the coagulated form appears to be the princi- 
pal agent in solid cytoblastemata, so dissolved fibrin seems 
of similar importance in those that are fluid ; indeed, its pre- 
sence seems to be a necessary condition for such formations 
as we are considering. This point is, however, so important 
that it ought to be accurately determined. It is possible in 
many cases to isolate, and consequently, when they occur in 
sufficiently large quantity, to analyse the fluid cytoblastemata 
of morbid products, as in exudations into the serous cavities, 
or in the formation of vesicles beneath the epidermis, where 
they are composed of water, fluid albumen and fibrin, fat, ex- 
tractive matters, and different salts. That aqueous solutions 
of salts and extractive matters are of themselves insuffi- 
cient to act as blastemata for organized products is placed 
beyond all doubt : they can act the part of mother-liquids, 
they can, in many cases, even enter into different struc- 
tures, (as for instance, salts of lime into the bones, and 
chloride of sodium, according to Lehmann, # into cartilaginous 
tissue), but organized formations can only be produced in 
them when a fibrinous fluid is also present, as for instance, 
when exudation occurs in the cavities of the uropoietic system, 
or of the digestive canal. The same is the case with the 
fats ; certain kinds admit of crystalline formations, (as cho- 

* Physiologische Chemie, vol. i. p. 133. 



PATHOLOGICAL EPIGENESES. 



107 



lesterin in gall-stones), andean also enter as constituents into 
organized formations, but can never of themselves alone, or 
in combination with salts and extractive matters, act as cyto- 
blastemata ; at least, up to the present time nothing of the 
sort has been observed. Hence there remain, as the actual 
and potential constituents of the blastema, only the protein- 
compounds ; although these are never found alone in the 
body, being always associated with the above named substances. 
Further, all these protein-compounds are not susceptible 
of development. Fluids which merely contain dissolved 
albumen and the above substances never appear to act 
as cytoblastemata. In the common dropsical effusions, 
which are always rich in albumen, we never observe any 
organized products, unless fibrin be also present : this is at 
least the result of my own observations, which have been very 
numerous, and I am not acquainted with a single exception 
to the law. # Moreover, fluids in which casein is the only 
protein-compound, cannot, as far as observation has yet 
shown us, act as blastemata. In the milk, for instance, as 
long as it contains merely casein, we never observe any patho- 
logical formations, for the granular bodies belong to the nor- 
mal process of development of the milk ; as soon, however, 
as any fibrin is present, morbid products, such as pus- corpus- 
cles, may be formed in it. On the other hand, in all fluids 
which we regard as cytoblastemata for morbid products, fibrin 
has always been found : hence we must regard it as the 
necessary and apparently the most essential ingredient in the 
cytoblastema. This law respecting the necessity for the 
occurrence of fibrin in the cytoblastemata of morbid products, 
which I have seen to hold good in several hundred cases, 
without a single exception, is not at all in accordance with 
the course of normal development : thus the egg, the proto- 
type of all formative fluids, contains no fibrin ; its place being 

* See the section on serous dropsy. 



108 



PATHOLOGICAL EPIGENESES. 



apparently supplied by albumen.* In the nutrition of the 
perfect organism, the general nutrient fluid, — the modi- 
fied blood-plasma permeating the walls of the vessels, — 
acts as the general cytoblastema for all new formations. 
Whether the fibrin is the only essential formative material in 
this fluid, or whether the albumen likewise takes part in deve- 
lopment, is a question which cannot be answered with the 
same degree of certainty as in the case of morbid products, 
since the normal fluid of nutrition can never be obtained free 
from extraneous constituents in sufficient quantity to be 
accurately analysed. 

If it appears certain that the protein- compounds are the only sub- 
stances capable of development in the human body, the question — 
which of them can act as a cytoblastema ? — does not admit of a posi- 
tive answer, since we at present possess but a moderately accurate 
knowledge of a few of the numerous modifications of this substance. 
This answer must, however, only be regarded as provisional, and will 
probably require considerable modification when we know more of the 
nature of the protein-compounds. 

When we have once established the principle that the 
blastema for morbid products must always be amorphous, 
the old idea is obviously overturned, namely, that a normal 
tissue may be directly converted into a pathological formation. 
Direct evidences will be subsequently adduced, when treating 
of individual morbid products.f 

Having now considered the chemical composition of the 
cytoblastemata of morbid products, another question presents 

* There may possibly be some connexion between this fact and the 
observation of Mulder, that the albumen of the egg contains one atom 
less of sulphur than the albumen of the blood, and that consequently 
in its ultimate composition it is identical with fibrin. 

f As examples of the amorphous solid cytoblastema, we may refer to 
pi. i. fig. 14, and pi. n. figs. 2 and 4, with the accompanying explana- 
tions. As a good illustration of the fluid cytoblastema, we may refer to 
the fluid of fibrinous dropsy. 



PATHOLOGICAL EPIGENESES. 



109 



itself — whence do they arise, and from what part of the hody 
are they produced ? In the present condition of our physical 
knowledge, I believe that no one will dispute with me, that 
without further preamble we may establish the principle as a 
general law, that the cytoblastema of every morbid product, 
as also of the tissues in healthy nutrition, is obtained from the 
vessels, and that its source is always the blood, or in some 
few cases the chyle or lymph. In normal nutrition the pro- 
position cannot be determined by direct observation ; but the 
grounds on which the probability is founded, are so sound, as 
to prevent the possibility of denial, for all the nutriment 
which in the latter instance the formative material conveys 
to all parts of the body, passes at length into the blood ; on 
the other hand, parts to which the supply of blood is checked 
or diminished are not at all, or only imperfectly nourished. 
In pathological epigeneses, it may often be directly observed 
that in consequence of inflammation, the plasma exudes 
through the vessels and forms the cytoblastema ; and in 
cases in which we observe no morbid secretion, it is 
more than probable that the ordinary nutrient fluid escapes 
through the vessels without inflammatory action, and thus 
forms a blastema for morbid products. 

Information on the processes by which this increased separation of 
plasma from the vessels is effected, has been already afforded in the 
section on fibrinous dropsy. I shall advert to the subject more fully in 
treating of inflammation. 

Organized morbid epigeneses are therefore produced in a 
blastema separated from the blood, and at the expense of the 
fibrin contained in it. Before we consider the processes 
which take place in development, we will take a glance at 
the question, — on what is the development of the cytoblas- 
tema dependant ? A purely chemical precipitation like those 
by which unorganized forms are produced, cannot in this 
case be regarded as sufficient, for while chemistry serves to 
point out the chemical differences between these formations, 



110 



PATHOLOGICAL EPIGENESES. 



we still cannot perceive how the various forms of the fibres 
and cells can proceed from it. By assuming a vital power, and 
referring all phenomena to it, we do not gain a single step ; 
since while we substitute these, as the foundation of all 
phenomena, we are even confessing that the latter is depen- 
dant on the entity of the organism, and is inexplicable to us : 
an insight into the primary causes of all formations is, how- 
ever, the point that most concerns us at present. 

In order to obtain a starting point, let us proceed from 
hypotheses. There are two different causes which may be sup- 
posed to affect the transition of the blastema in development ; 
firstly, the cause may be grounded on the nature of the cyto- 
blastema, and the formation may be developed with the same 
necessity which, under favourable conditions, compels the sepa- 
ration of certain crystals from their mother-liquid : or secondly, 
the transition in the development may be dependant on exter- 
nal conditions, independent of the cytoblastema, as for in- 
stance, on the influence of the surrounding parts of the body, 
&c. In order to ascertain which of these two hypotheses is 
deserving of preference, it is requisite that every one should 
have perfectly clear and distinct ideas on the following points. 
We must distinguish between the capacity of the cytoblastema 
in the progress of development (potentia), and the actual 
transition (actus). That the capacity for development essen- 
tially pertains to the cytoblastema, no one will deny. If it 
depended merely on external influences, then would any sub- 
stance placed in similar relations undergo the same process of 
development— an assumption entirely at variance with expe- 
rience. In this respect the cytoblastema of a morbid product 
resembles an egg or a seed ; it differs, however, in the cir- 
cumstance of its actual development (the transition of the 
potentia into the actus) being much more dependant in exter- 
nal conditions. Its development is not merely dependant on 
the same general conditions as those of the egg, which is 
developed out of its mother's body, (namely on the presence 
of warmth, moisture, and oxygen ;) in the majority of cases, 



PATHOLOGICAL EPIGENESES. 



Ill 



it is likewise requisite that it should he connected with the 
hody of a living individual : a blastema for morbid products, 
can, as a rule, only be developed when it is in connexion 
with, and reacting on a vital part of a living body. After 
death no cytoblastema is developed in the body : moreover, 
in parts of the living organism, in which vitality has been 
destroyed by gangrene, there can be no further develop- 
ment. 

Of course this is not the case with, independant organisms. Fungi and 
infusoria may be formed in the dead body. Moreover the coagulation of 
fibrinous fluids after death does not fall under this head, for the coagu- 
lation of fibrin is a process unconnected with development. We can at 
any rate include here the fibrinous flakes* (Faserstoffscholleri), described 
by H. Nasse, although I could not convince myself of their existence 
after a series of observations conducted with the greatest care. On the 
other hand there appear to be isolated exceptions to the above rule, and 
cases apparently occur in which we must assume that pathological ele- 
ments, especially pus-corpuscles, can be produced without the contact 
of organized tissues, indeed, even externally to the body. Thus Hel- 
bertf has recently observed, that the fluid of a blister, produced by can- 
tharides, which on its discharge contained no corpuscular particles, after 
standing five or six hours in a glass contained granular cells (imperfect 
pus-corpuscles), and he has even followed their progressive formation 
under the microscope. (Figs. 1, 5, 6, and 7 of the plate attached to his 
Dissertation.) I shall again refer to this subject in speaking of the for- 
mation of pus, when I shall give some other examples of independent 
cell- formations unconnected with organized parts. The develop-, 
ment of a cytoblastema without either the influence of surrounding 
organized parts, or a previously exciting germ is, however, rare, 
and appears to be limited to very simple formations, such as pus -cor- 
puscles. Moreover, the greatest caution is necessary in carrying on such 
observations as those of Helbert. In the microscopic examination of a 
fluid containing a few scattered particles in suspension, it frequently 
happens that those particles escape detection, till the fluid has stood for 
some time, and they have gravitated to the bottom of the vessel. In 
such cases the observer might be readily deceived, and led to believe 
that these bodies were actually produced in the fluid in the vessel. 



* Miiller's Archiv. 1841, p. 437. 

f De Exanthematibus arte factis fragmenta, Gottingic, 1844, p. 16. 



112 



PATHOLOGICAL EPIGENESES. 



If after the above observations it hardly can be doubted that 
the capacity for development is inherent in the cytoblastema, 
and that the actual development is modified by exter- 
nal influences; the important question still remains — what 
share the cytoblastema has in the development, and what 
share is due to external influences ? Taking a general view of 
the question, we find considerable differences on this point. 
In the formation of the animal organism from the egg, the 
share of the cytoblastema is very predominating; there is 
contained within it not merely the capacity, but likewise the 
whole quality of the future formation : in fact, the whole of 
the future organism is included in the egg : external circum- 
stances can hinder, but cannot essentially change it. When 
speaking of the theory of malformations, we shall consider 
this subject more closely. In the nutrition of the perfect 
organism, the case is different ; we here observe the various 
tissues of the different organs evolved from the blood, 
or rather from the general nutritive fluid, — as cellular 
tissue, bone, muscle, and nerves. The element of this diffe- 
rence cannot therefore lie in the blastema; it must rather 
be sought in the ready-formed parts of the body, which 
influence the blastema to the development of parts similar to 
themselves. We must accordingly conclude that the forma- 
tive capacity, which being equally diffused through the egg is 
impressed on the whole blastema, now acts at special points, 
and on those individual tissues which have the capabi- 
lity of exciting a development in a suitable blastema, leading 
to the formation of analogous compounds within its sphere 
of action, that is, in its immediate neighbourhood. This is 
a formative act similar to that by which an entire organism 
enables a cytoblastema to develop an individual similar to 
itself. The nature of the blastema is not, however, to be 
regarded as a matter of indifference in this process ; it can 
generally only be traced in the development, when it possesses 
a definite chemical composition, and on this, as well as on 



'pathological epigeneses. 



113 



the chemical changes which the blastema undergoes in its 
development, the chemical part of nutrition is dependant. 

Let us now apply this to morbid products. Numerous 
cases present themselves in which the epigenesis takes 
place in a manner perfectly analogous to that which occurs 
in healthy nutrition. Thus, in the process of regenera- 
tion and in hypertrophy, where the influence of the cyto- 
blastema on the nature of the development is at its 
minimum, the development itself appears to be entirely de- 
pendant on the normal histological elements between which 
the blastema is effused. Thus, in regeneration and hypertro- 
phy, the blastema between areolar tissue, becomes areolar 
tissue ; in the vicinity of bone, it becomes cartilage and 
bone ; between muscular fibres, it is converted into similar 
tissue ; at the extremities of divided nervous fibrils, it forms 
nervous substance, &c. The circumstance that these and 
no other structures are formed, cannot in these instances 
be dependant on the blastema, which as far as chemical 
analysis goes, seem to be the same ; and it is entirely the 
influence of the surrounding parts that modifies the character 
of the development. Here then, if we may be allowed the 
expression, we are entering the department of solid patho- 
logy. 

But it may be further asked: it being granted that 
in the above cases, the nature of the development is essen- 
tially dependant on parts of the body already formed, what is 
the case with those pathological epigeneses in which the 
resulting morbid product is perfectly different from the sur- 
rounding parts, as in scirrhus, encephaloid, tubercle or 
pus? Is not the abnormal character of the product de- 
pendant on a peculiar pre-existing blastema, so that there is 
always one kind of blastema for scirrhus, another for ence- 
phaloid, and so on ? 

We are yet hardly in a condition to answer this question 
satisfactorily. It is quite possible that the elements of the 
peculiar structures of scirrhus and encephaloid may be 

VOL. I. I 



114 



PATHOLOGICAL EPIGENESES. 



traced to the blastemata from which they spring, and 
that in accordance with the views of the humoral pathologists, 
the pseudo-plasma may be dependant on an abnormal chemical 
composition of the blood. Another explanation may be 
attempted which equally elucidates the appearance of these 
peculiar morbid products, namely, that the peculiarity of the 
epigenesis is not dependant on any property of the blastema, 
but on changes in the properties of the tissues influencing 
the blastema ; and thus the explanation of these phenomena 
is again transferred from the department of humoral to that 
of solid pathology, or, since in many cases these changes are 
dependant on a change in the nervous influence, to that of 
nervous pathology. It is, however, in the highest degree 
probable, that in the majority of cases neither the one nor 
the other of these views alone is strictly correct, that for the 
most part changes in the cytoblastema and changes in the 
physiological properties of the tissues are conjointly at work 
in producing an abnormal epigenesis. 

These brief observations on a much -disputed question 
must for the present suffice. The only possible method of 
thoroughly testing the subject is by an examination of individual 
pathological epigeneses. 

The nature of the development of pathological epigeneses is 
dependant on; 

1. The cytoblastema, the quantity, quality, and mode of 
its production. The more rapidly and abundantly it is se- 
creted, and in proportion as the chemical composition (which, 
however, is certainly not accurately known) differs from the 
normal blood-plasma, so does the influence of the surrounding 
histological elements decrease, and the formation proportio- 
nally deviate from the normal type. Thus small quantities 
of exudation become easily organized, and simple hypertrophy 
usually consists in small exudations repeatedly occurring 
after long intervals (weeks or months). We can draw no 
very definite limit between this process and that of healthy 
nutrition. Abundant and rapidly formed exudations are 



PATHOLOGICAL EPIGENESES. 



115 



rarely organized, usually proceeding to suppuration. Exuda- 
tions undergoing incipient putrefaction — as, for instance, ichor 
- — do not become organized ; and where the composition of the 
blood, (and consequently the exudation proceeding from it,) 
differs considerably from the normal type — as is probably 
the case in typhus and scrophulosis — either no organi- 
zation follows or else it occurs very imperfectly, as we shall 
presently see when speaking of typhous matter, scrophulous 
depositions, and similar products. 

2. The nature of the development is influenced by the his- 
tological elements of the part in which the epigenesis occurs. 
If the influence of these parts predominates, the newly formed 
material resembles the pre-existing normal tissue, and thus in 
morbid hypertrophy, in regeneration of lost parts, &c, the 
process is just the same as in ordinary nutrition.* This 
important law which plays a very active part in pathological 
epigenesis, I will for brevity term " the law of analogous 
formation." 

The law of analogous formation, is, however, essentially 
modified by the nature and vital properties of the parts in 
question : 

A. The more complex in structure the tissue is in which 
the epigenesis occurs, so much the less does it resemble the 
normal elements. Areolar tissue, osseous tissue and 
simple (non-striated) muscular fibre are easily reproduced, 
nerves not so readily and more slowly, whilst complex organs, 
such as the tissue of the lungs, brain, &c, are either not 
reproduced at all, or only very imperfectly. The extent of 
this law varies considerably in different organisms ; while in 
men and the higher animals, the regenerative power is very 
limited, or, if I may use the expression, the power of pro- 
ducing histological elements from the cytoblastema is at its 



* This law is clearly laid down by Meckel ; he observes that morbid 
epigeneses resemble the adjacent normal structures. Path. Anat. vol. n. 
Part ii. p. 213. 

I 2 



116 



PATHOLOGICAL EPIGENESES. 



minimum, in the lower animals where whole organs can be 
reproduced, this power is much more energetic. 

B. In proportion as the physiological properties of the 
parent-tissue deviate from the normal type, so much the more 
heterogeneous will be the epigenesis. Thus in gangrenous 
parts the exudation admits of no normal development ; and 
the same is the case in parts in which the nerves have been 
divided. In structures which have been changed by chronic 
inflammation, or of which the physiological properties of the 
elementary parts differ for any reason from the normal type, 
pathological epigeneses are produced distinct from those that 
occur in healthy parts. 

The cytoblastema on the one hand, and the pre-existing tissues 
on the other, are each factors influencing the formation of 
organized morbid products, and it is on their different pro- 
perties that these epigeneses are dependant both for their 
mode of formation, and for their general characters. 



Having dismissed these questions, let us now advert to 
the processes that take place in these morbid developments. 
Schwann in confirmation of his cellular theory,^ has made 
the remark, that he has observed its application to a large 
number of morbid products. Since that date numerous 
observations have been published which support this view. 
Schwann's theory of cellular formation has, during the last 
few years, been attacked from many quarters, or at least 
adopted with modifications, as by Arnold, Henle, and Vogt,f 
while ReichertJ has stood forth as its advocate. According 
to Schwann, development is always dependant on a formation 
of cells in an amorphous cytoblastema, and the formation 

* Mikrosk. Untersuch. iiber die Uebereinstimmung in der Structur 
der Thiere und Pflanzen, 1839. 

t Unters. iiber die Entwicklungsgeschichte der Geburtshelferkrote, 
1842, p. 117, &c. 

X Miiller's Archiv. 1842. Jahresbericht iiber die Fortschr. der 
mikrosk. Anatomie. 



CELLULAR FORMATION. 



117 



proceeds in this manner. In the first place, one or more 
minute granules (nucleoli) appear, around which the cytoblast 
(nucleus) is formed, and this again becomes surrounded with 
a membrane (the cell-wall) which at first closely envelopes 
it, but subsequently in the course of its growth, becomes 
separated from the nucleus, thus leaving a cavity between it 
and the cell-wall. This is termed the cavity of the cell, 
and is filled with a substance differing essentially in 
character both from the nucleus and the cell-wall. In the 
cell thus produced, the nucleus is not in the central 
point, but is situated eccentrically at a point on the inner 
surface of the cell-wall. It is from these cells alone, by a 
process of further development, that all organized products 
arise. 

That this mode of development from cells occurs in patho- 
logical epigeneses may be readily shown in numerous cases. 
This process can be most obviously traced in the formation 
of pus-corpuscles, when they are produced from a fluid 
blastema on a free surface, or in a cavity connected with 
the exterior of the body. In such a case, we first observe 
numerous isolated granules,* which become surrounded by a 
very delicate transparent cell-membrane,f which subsequently 
forms so thick and opaque a wall, that the nucleus can no 
longer be seen through it ;{ on the addition of acetic acid, which 
dissolves the cell-wall, or at any rate renders it transparent, 
the nuclei again become visible. || If it is impossible to 
trace the whole course of development in one and the same 
cell, we can yet make out the successive changes of the whole 
mass of cells with sufficient certainty. These and similar ob- 
servations, such as for instance may be made on the formation 
of epithelium, confirm the opinion that in all essential points 
Schwann's theory is applicable to morbid formations ; but 
that in individual cases, many facts may be observed which 



* Plate in. fig. 6, a, b. 
X Plate in. fig. 6, a, a. 



f Plate in. fig. 11, a. 
|| Plate in. fig. 9, b, 



118 



PATHOLOGICAL EPIGENESES. 



do not coincide with this theory, or at least render some modi- 
fication imperative. 

With respect to the early relations of the nucleus and the 
nucleolus, I cannot convince myself of the existence of 
the nucleolus prior to the nucleus, or at least that the nu- 
cleolus is, as it were, the means of forming the nucleus in 
the same way as the nucleus forms the cell. In some cases 
this may happen, but certainly not in all. I must agree 
with Henle in opposition to Reichert, in believing that 
Schwann's cellular theory represents only one of the various 
forms of development, of which the type in different cases 
may present very numerous differences. 

The nuclei of morbid formations present great differences 
both in form and size ; they are round or oval, # or occa- 
sionally elongated and pointed, as in the formation of areolar 
tissue, and simple muscular fibre. f Nucleoli are sometimes 
clearly visible, usually one or two in number, but occa- 
sionally three or four ; sometimes, however, no trace of a 
nucleolus can be detected. In many cases the nucleus has a 
well-defined, regular outline; in others, this appearance is 
absent, and it then occurs as an aggregation of minute, 
indefinite granules, or as a soft mass without any well-defined 
limit. In this point of view, morbid products of the same 
kind present great differences, as for instance, pus-corpuscles, 
in which the nucleus consists of an aggregation of minute 
granules, sometimes quite unconnected with each other, and 
sometimes united by a connecting medium presenting per- 
fectly distinct chemical properties, so that in this case great 
differences occur in the form of the whole nucleus, as well 
as in the mode of deposition and properties of the individual 
molecules. The size of the nucleus is always very minute, vary- 
ing in diameter from the 600th to the 100th of a line, but 
seldom exceeding the 200th : the only exception is in the case 
of elongated fusiform nuclei, which may exceed the 100th of 



* See Plate i. 



t Plate iv. fig. 4. 



CELLULAR FORMATION. 



119 



a line. The nucleoli are, however, much smaller, their 
diameter seldom exceeding the 1000th of a line. 

The chemical relations of the nucleus are very remarkable. 
It possesses the property of resisting the action of acetic acid, 
a reagent which attacks the solid cytoblastema in which the 
nucleus is situated, as well as the cell-wall surrounding it, 
rendering the latter pale and sometimes causing its total dis- 
appearance. Hence acetic acid affords the means of rendering 
the nucleus visible when it is hidden by the cytoblastema or 
the cell-wall. In pus-corpuscles, where the relations of 
the nucleus are very peculiar, the addition of acetic acid 
usually causes it to break up into minute granules. By 
the prolonged action of a solution of borax, caustic 
ammonia, and more rapidly by caustic potash, we find 
that the nucleus and the cell-wall disappear simulta- 
neously, being dissolved by these reagents. After this solu- 
tion is effected, there usually remain minute granules appa- 
rently composed of fat, for on extraction with ether, 
previously to applying the alkalies, they did not appear. 
These are regarded by Messerschmidt and Lehmann* as 
the nucleoli of the pus-corpuscles; but I do not believe 
that they stand in any special relation to the nucleus, since 
they do not occur in all nuclei, and may further occur free 
in a fluid containing cells. 

Relations of the cell-wall generally, and especially towards 
the nucleus. — Observations on the development of morbid 
products teach us that sometimes the facts are precisely in 
accordance with the general law laid down by Schwann, but 
that there are likewise exceptions to this rule. Undoubted 
cells are sometimes observed in pus- corpuscles, and generally 
in encephaloid and scirrhus. The form and magnitude of 
these cells are extremely variable ; they are usually round or 

* Messerschmidt de pure et sanie, Lipsise, 1842, p. 11. Lehmann 
u. Messerschmidt iiber Eiter und Geschwiire. Archiv. v. Roser und 
Wunderlich, vol. i. 



120 



PATHOLOGICAL EPIGENESES. 



oval, # sometimes elongated and fusiform,! and occasionally 
quite irregular.]: It is, however, only rarely that we can 
distinguish in them a decided membranous cell-wall, and a 
cavity distinct from it ;§ the cell most commonly appears 
as an homogeneous mass (with the exception of the nu- 
cleus) so that we can distinguish in it the substance of 
the nucleus and the substance of the cell, but no cavity. 
Even in pus-corpuscles the sharp external outline is some- 
times absent, so that here we have no definite and limited 
deposition around the nucleus. This opinion, first suggested 
by microscopic observation, is confirmed by the laws of 
endosmosis. For while on the addition of water to pus- 
corpuscles with an undoubted cell-wall, the membrane 
constituting the wall becomes first dilated, and then bursts 
and liberates the nucleus, pus-corpuscles without a decided 
cell-wall merely become swollen, without rupturing them- 
selves. Hence, in addition to the kind of cellular formation 
described by Schwann, according to which the cell consists 
of a constricted membrane surrounding a nucleus, we must 
assume a second kind, in which a somewhat indefinite preci- 
pitation occurs around the nucleus. 

Moreover, the relation of the cell-wall to the nucleus in 
morbid products differs in many points from Schwann's 
theory. A species of cellular formation occurs in which there 
are no pre-existing nuclei ; thus pus-corpuscles without nuclei 
are often observed ; they are usually of an irregular form, and 
after the application of acetic acid leave only a few (fatty) 
granules, and sometimes not even these. || These non- 
nucleated pus-corpuscles are always formed in large quantity 
in unhealthy suppuration, and apparently not singly amongst 
normal corpuscles ; hence, in these cases the whole process of 
development appears from some general cause to undergo an 



* Plate i. figs. 1—6, and 13. 
X Plate i. fig. 1 1 . 
|| Plate in. fig. 7. 



f Plate i. fig. 12. 
§ Plate i. fig. 2. 



CELLULAR FORMATION. 



121 



essential modification. Under this form of non-nucleated 
cellular formation, we must include the fibrinous flakes 
(Faserstoffscholleri) described by H. Nasse, # if their general 
occurrence be confirmed. I have never yet succeeded in de- 
tecting them, although I have repeatedly sought for them 
both in blood and in exudations, and other observers have 
been equally unsuccessful. J. Meyerf explains them as being 
merely epithelium rubbed from the walls of the vessels. The 
non-nucleated corpuscles, somewhat resembling fibrinous 
flakes, which occur in encysted tumours, and in pus from 
glandular organs,! I certainly regard as epithelium. Hence 
the absence of the nucleus may be easily referred to resorp- 
tion, as certainly the older cells of the epidermis are non- 
nucleated. Colloid of the thymus presents another non- 
nucleated structure, which externally appears as if it were 
cellular. If we agree with Nasse in regarding these forma- 
tions as not composed of cells, but constructed according to 
distinct laws, nothing is gained by such a supposition. The 
cellular theory, if a general law of development is to be 
founded on it, must take cognizance of all these phenomena, 
and must endeavour to explain them in accordance with its 
own doctrines. Sometimes the absence of the nucleus in a 
cell is only apparent, being concealed by the cell-wall, and 
coming in view after the addition of acetic acid : in other 
cases the nucleus is formed and becomes resorbed, as takes 
place with the cells of epidermis and various epithelia. 

Besides the cases in which cells are devoid of any nucleus, 
there are others to be considered, in which a cell contains 
more than a single nucleus. This phenomenon admits of a 
double explanation ; firstly, the composite nucleus might be first 
produced, and a simple cell formed around it ; or secondly, 
another cytoblast may form within a cell containing a single 

* Miiller's Archiv. 1841, p. 437. 

t Froriep's N. Notizen, 1843, No. 560. 

t Plate i. fig.- 3, pi. Hi. fig. 9. c. d. 



122 



PATHOLOGICAL EPIGENESES. 



nucleus. In fact, both these modes of formation actually 
occur. It has been already stated that the nucleus of pus-cor- 
puscles is not simple, but consists of several (2 —4) portions. 
We frequently observe that these composite nuclei are present 
before the cell is formed. Sometimes I have seen, in a 
pus-corpuscle, several such nuclei consisting of minute nucleoli; 
once I noticed as many as four, so that the whole of the pus- 
corpuscle was filled with granular matter, the individual 
portions of which were not clearly defined. The second 
mode of formation, that namely in which the nuclei are 
formed subsequently to the production of the cell, is of ordi- 
nary occurrence in vegetable cells and in cartilage. Here the 
newly formed cytoblasts act as central points for a new for- 
mation of cells, and then there arise cells within cells — 
parent cells and their offspring. Moreover, this process may 
be observed in morbid products, as in encephaloid, where we 
often find cells with many nuclei, and parent-cells with their 
offspring.* 

It has been already mentioned that Schwann's opinion, 
that every cell possesses a decided cell-wall between which 
and the nucleus there is a cell-cavity filled with a matter 
differing from the cell-wall, is incorrect. Numerous cases, 
however, occur in which these points strictly accord with the 
laws of the cellular theory. A decided wall with a double 
contour, sometimes occurs in cancer-cells.f 

In all probability the cell-wall invariably consists of a 
protein-compound, and it is chemically distinguished from 
the nucleus by being rendered transparent by acetic acid, and 
frequently after prolonged action being altogether dissolved. 
A similar reaction occurs on the addition of solutions of borax, 
caustic ammonia, and (more powerfully) of caustic potash. 
Recent cells have usually a homogeneous cell-wall, which 
subsequently becomes opaque, and covered with a granular 
matter, usually insoluble in acetic acid and in alkalies, 



* Plate i. figs. 6 and 7. 



f Plate i. fig. 2; pl..vin. fig. 9. 



CELLULAR FORMATION. 



123 



but soluble in ether, and therefore probably of a fatty 
nature. 

The contents of the cell, when they are distinct from 
the cell- wall, are usually fluid. They cannot be detected 
by the eye, and their presence can, therefore, only be inferred 
by the circumstance that the cell collapses when bursting 
under the compresser, and that its fluid contents escape. 
They form a tolerably concentrated solution of matter soluble 
in water, as their relation in respect to endosmosis testifies, 
for on placing such cells in pure water, they swell till they 
burst, since their contents by endosmosis absorb water ; in 
concentrated saline solutions, on the other hand, they shrivel, 
since they lose water by exosmosis. Sometimes the cells 
contain fluid fat in the form of drops, which may be distin- 
guished under the microscope from the surrounding fluid by 
their different refracting power. # The solid contents of cells 
are usually granular, and the granules are most commonly 
devoid of colour ;f but sometimes they are black, brown, or 
orange. The chemical properties of these contents are 
various ; sometimes the granules consist of fat, and are then 
soluble in ether; sometimes of calcareous salts, in which 
case they dissolve in acids. As examples of cells with 
coloured contents, we may mention those containing black 
pigment.^: and yellow bile-pigment. § Moreover, crystalline 
deposits sometimes occur within cells, crystalline groups of 
margarin being occasionally noticed in fat-cells. || It is not 
always easy to distinguish whether granular matter is actually 
within the cell, or only deposited on its walls. 

According to the theory of Schwann, who ascribes the 
formation of all structure to cells, the process of develop- 
ment is not completed by the above mentioned formation : 
the cells undergo further changes, and do not follow the 



* Plate i. fig. 9. 
X Plate i. fig. 10. 



124 



PATHOLOGICAL EPIGENESES. 



type in accordance with which they were first formed, but 
differ very considerably in different structures. These 
changes may be divided into two groups depending on the 
properties of the product developed from the cells. It is 
the very same distinction as we meet with in the consideration 
of the elementary parts of the normal organism. In the first 
group we include those organs which, in their highest stage of 
development, retain their cellular formation, as for instance all 
epithelia, the blood-corpuscles, and the cellular constituents 
of the liver, kidney, and other glands. In the second group 
we include those parts in which the original cells undergo 
further modifications which destroy their cellular type. This 
is likewise the case with morbid products, and it may happen 
that either : firstly, the organized product is completed by the 
formation of cells ; or secondly, the cells altogether lose their 
characters as cells, and become changed into different tissues, 
with whose formation and perfection the process of develop- 
ment is concluded, and its object thoroughly attained. 

Let us now proceed to consider these possible relations 
somewhat more closely. 

1 . The morbid development may remain as a cellular 
formation, and the original cells having attained their 
highest degree of development, may undergo no further 
metamorphosis into other tissues. 

In the morbid products belonging to this class there are 
yet further differences to be noticed, namely, a. whether the 
cellular formation is persistent, and in its perfect form con- 
stitutes a fixed constituent of the organism ; or, b. whether 
the cells are transitory, breaking up and being rejected or 
resorbed without being of any service to the organism, or 
contributing any permanent constituent to it. 

This distinction has reference not so much to the individual cells as 
to the tissues formed from them : moreover, in the persistent cellular for- 
mations the individual cells become gradually broken up in the process 
of metamorphosis, but new individuals are developed with the same rela- 
tions, so that the integrity of the tissue is maintained inviolate, while 



CELLULAR FORMATION. 



125 



in the second division the whole structure breaks up simultaneously with 
the destruction or removal of the individual cells. 

a. PERSISTENT CELLS. 

The chief parts of the human body which in their perfect con- 
dition are composed of cells, either directly connected with one 
another, or united by a very minute quantity of intercellular 
substance, are the epidermis, the epithelia of mucous and serous 
membranes and of vessels, the internal cellular investment of 
ducts in glandular organs, and fatty tissue. Moreover, the 
cartilages (with the exception of fibrous cartilage) belong in 
some measure to this class, if we regard their structureless 
intercellular substance. 

When, by a morbid process, any of the above-mentioned 
structures are produced anew, the process of epigenesis is 
exactly the same as that of the original formation in embryo : 
it follows that the cells formed from the cytoblastema gra- 
dually assume the form and properties which pertain to the 
normal cells of the newly formed tissue. Hence the whole 
change undergone by the original cells consists in this, that 
they gradually become similar to the cells of the normal tissue 
which they are to repair. The changes thus occurring in the 
primary cells may in special cases be very different ; they may 
become flattened and increase in breadth, as in pavement 
epithelium, or they may increase in length, and assume a 
conical form, as in cylindrical epithelium. 

This mode of formation of the persistent cells can be most readily 
observed in the restoration of destroyed epithelium, as after burns or 
blisters. We shall notice especial instances when speaking of the epi- 
genesis of epidermis and epithelia. 

b. TRANSITORY CELLS. 

While the above-mentioned persistent cellular forma- 
tions exist in the normal body and are subservient 



126 



PATHOLOGICAL EPTGENESES. 



to organic life, and to certain definite objects — as protec- 
tion from without, secretion, or absorption — so also in mor- 
bid processes, we very frequently meet with a species of 
cellular formation, in which secondary cells which have 
proceeded from primary cells discharge no functions con- 
nected with the vital process. These do not remain con- 
nected with each other, but separate, and are either discharged 
as foreign matter from the organism, or when this does not 
or cannot happen, being capable of no further development, 
gradually break up, until they are at last reduced to a nearly 
structureless, finely granular mass, which (like any other 
mass incapable of acting as a cytoblastema) gradually sepa- 
rates, as far as is possible, from the fluids of the body, and 
at last for the most part or entirely disappears. 

A large number of morbid products fall under this head ; for instance 
pus and what are termed malignant epigeneses, such as tubercle, ence- 
phaloid, and scirrhus, whose descriptions are subsequently given. 

2. The cells may he converted into other forms. — 
Instead of being converted into secondary persistent cells 
or being altogether destroyed, the original cells may be con- 
verted into other structures, which in their perfect state 
have entirely lost the original cellular form. The processes 
by which this takes place are very different, depending 
on the properties of the tissue to be constructed from 
the cells ; they admit, however, of division into two funda- 
mental types. 

A. Several cells may be fused together by the uniting of 
their walls. Thus according to Schwann are formed blood- 
vessels, nerves and muscular fibre. 

b. The cells may become divided, each individual cell 
separating into different parts. This is observed in the 
development of cellular tissue. 

We shall enter with more minuteness into the genesis of these struc- 
tures, when treating of the morbid formations occurring in the individual 
tissues. 



CELLULAR FORMATION. 



127 



The above seheme enables us to take an easy review of the 
different organized morbid formations, and further, as will 
be presently shown, it has its practical uses. It is founded 
on Schwann's theory of development. It presupposes that 
all organized forms are composed of primary cells, — a suppo- 
sition which in relation to normal development has been op- 
« posed on many sides, and in relation to morbid products 
cannot be very strictly carried out. In our observations on 
morbid cells, we have shown that their development does not 
in every point coincide with Schwann's theory ; there are 
numerous exceptions in the transitory formations, namely, 
in the tissues which in their perfect condition do not retain 
the cellular form. In these cases we frequently cannot detect 
any cellular formation throughout the whole process of deve- 
lopment, or at most a mere analogy — a faint tendency 
to the formation of cells, but no such actual production. 
This occurs in scrophulous and typhous exudations, and in a 
great part of the cases of tubercle. Here we first have an 
amorphous or finely granular exudation (blastema) forming a 
tenacious and tolerably firm mass, which by degrees breaks 
up into a more or less fluid magma, exhibiting under the 
microscope indefinite granular molecules of various forms and 
sizes, sometimes resembling cytoblasts and cells, but never 
indicating a decided cellular formation. 

Further there are produced in many fluid cytoblastemata, 
partly together with regular cytoblasts and cells, and partly as 
isolated formations, minute indefinite granules (elementary or 
molecular granules) which sometimes appear to form consti- 
tuent elements of future cells, but as frequently to remain for 
a long time unchanged, and finally without undergoing any 
further metamorphosis to disappear or be discharged. They 
are not invariably, (indeed not even for the most part), fat- 
vesicles with a definite wall, as Henle* supposes, but solid 
granules which apparently consist sometimes of fat, and 



* Allgemeine Anatomie, p. 163. 



128 



PATHOLOGICAL EPIGENESES. 



sometimes of the salts of lime, or of a modified protein- 
compound. These elementary granules are frequently arranged 
in somewhat regular groups, clinging together and forming 
by their union large granular bodies (aggregate corpuscles) 
which sometimes so closely resemble cells that scarcely any 
difference can be observed. Indeed, it appears that such 
groups of molecular granules may even be invested with an 
actual cell-wall, and thus form true cells. 

In all these cases of morbid epigenesis, we find no decided 
cellular formation, such as should occur according to Schwann's 
theory ; on the contrary, these cases approximate towards the 
mode of formation of unorganized depositions, forming a sort 
of transition between them and organized morbid epigeneses. 

The above mentioned elementary granules are of very frequent occur- 
rence, and we shall often have occasion to revert to them. They occur as 
very minute granules of an indefinite rounded form, and vary from the 
800th of a line to a size too small to admit of measuring. Differing as we 
have shown in their chemical characters, they behave differently towards 
reagents. Those of most common occurrence seem to consist of coagu- 
lated protein-compounds and resist the action of most reagents. 
Neither acetic nor nitric acid, nor yet caustic ammonia or potash, nor 
ether cause them to disappear. Those consisting of fat dissolve in ether 
with the aid of heat. Those finally which consist of calcareous salts (phos- 
phate and carbonate of lime) disappear on the addition of nitric acid, 
in the latter instance with the development of air-bubbles. There can 
be no doubt that these elementary granules are always deposited in a 
fluid condition, and subsequently assume the granular form either by 
coagulation or chemical precipitation. 

In those completely organized morbid products which in 
their perfect condition, no longer retain the cellular form, it 
is only rarely that any decided cellular formation can be 
detected during the period of development, as according to 
Schwann's theory must always be the case. Thus in the 
development of areolar tissue and of fibrous tissue, we 
certainly sometimes find cells which are prolonged into fibrils, 
but more frequently we meet with mere cytoblasts without 
decided cells (with a wall, cavity, and contents), and the 
blastema appears to be converted directly into fibrils : indeed, 



CELLULAR FORMATION. 



129 



sometimes we observe the formation of fibrils without even the 
pre-existence of a decided cytoblast. This and many similar 
observations which we shall notice when speaking of the 
different tissues confirm the opinion that Schwann's theory 
requires considerable modifications before it can be applied to 
morbid tissues, and further that all perfectly formed tissues 
do not originally possess a decided cellular formation ; this 
cellular structure in some cases existing only for a short time, 
as during the formation of the cytoblast, and in other cases 
not at all. As, however, our knowledge respecting the deve- 
lopment of the different morbid formations is still very defi- 
cient, we must rest satisfied with the above statement, and 
refer individual observations to the departments under which 
they naturally fall. 

The processes we have hitherto considered have reference 
principally to the morphology of development. It has been 
already stated that with this morphological change there is also 
a chemical change in the cytoblastema. We have seen that as 
in the cellular formation of the blastema there are chemical 
differences, so the nucleus differs in its chemical reactions 
from the surrounding cell-wall. This chemical change is still 
more important, when perfectly organized forms, as areolar 
tissue, muscular fibre or nervous matter have been produced 
from the original blastema, since all these substances, as a 
general rule, differ considerably in their chemical composition 
from their cytoblastema. Thus, for instance, from coagu- 
lated fibrin there may be formed areolar tissue consisting 
of gelatigenous tissue, or cartilage which on boiling yields 
chondrin, or osseous tissue which in addition to gelatin 
contains a large amount of calcareous salts. We are far from 
being in a position to lay down general chemical laws regu- 
lating these formations. We can certainly compare the 
chemical formula for the cytoblastema with that for the 
product formed from it, and calculate how many atoms of 
oxygen, carbon, hydrogen, or nitrogen must be deducted or 
added, in order to convert the one into the other, but such 

VOL. I. K 



130 



PATHOLOGICAL EPIGENESES. 



a proceeding is in most cases a mere sporting with formulae, 
which in some instances may give probable results, but here, 
when we are attempting to form general laws, is altogether 
out of place. I, therefore, reserve the consideration of this 
subject till the tissues individually are considered. 

We have already stated sufficient to show the undeniable importance 
of Schwann's cellular theory in contributing to our knowledge of the 
development of morbid epigeneses. This theory gives us the key to the 
understanding of a large number of processes, by enabling us to take a 
general view of them. But in its original form it is not sufficient 
to explain all the phenomena which occur in the development of 
morbid products. Since, as has been already shown, it is impossible to 
include all the phenomena relating to morphological relations in our 
general laws, it is naturally far more difficult to indicate the general 
causes of development, or, in other words, to give a general theory of 
the development of organized epigeneses. This is the more difficult 
since the chemical bearings of the subject, which require as much atten- 
tion as the morphological, have hitherto been much neglected ; and for 
that reason I shall not attempt to establish any such theory. 

SPECIAL RELATIONS OF ORGANIZED PATHOLOGICAL EPIGENESES. 

The final results of the development of the pathological 
epigeneses already described are in special cases very different. 
Some of the products are of a fluid nature — emulsions, which 
like the blood, contain organized solid parts suspended in a 
liquid ; others are solid. The latter are tissues which are in 
all respects identical with those of the normal body, as areolar 
tissue, epithelia, vessels, cartilage, bone, &c. ; or on the other 
hand, they may be of a peculiar nature to which there is 
nothing analogous in the normal body, as for instance, 
tubercle, encephaloid, scirrhus, &c. 

In many cases the newly formed tissue is homogeneous ; 
in others, on the contrary, it is composed of very different 
elements. 

In another point of view, the newly formed tissue is either 
persistent, or in other words, forms a permanent part of the 
body, and is there nourished like any other portion of the 



REPARATION CICATRICES TUMOURS. 



131 



system ; or else it is transitory, and after a time softens, breaks 
up, and is removed. 

This is the leading difference between non-malignant and 
malignant epigeneses. 

Further, morbid epigeneses may be classified : 

1 . Into such as form a reparation of a lost part (regenera- 
tion). These regenerated parts are either : 

A. Perfectly formed, the newly constructed part being 
similar to that which was lost, both in its morphological, 
chemical, and functional characters (true reparation). This 
true regeneration always follows the law of analogous forma- 
tion, and in the human body is confined to simple tissues ; 
in the lower animals it exists on a much more extensive 
scale. 

B. Or they are imperfectly formed (cicatrices). Cicatrices 
are sometimes transitory, existing only so long as the morbid 
product is continuing to be developed. When it is completed, 
the new tissue is perfectly similar to the old, and the cicatrix 
disappears. In other cases the cicatrix is persistent. The new 
parts then remain undeveloped and half- amorphous, or they 
are composed of elements of lower physiological importance, 
as of areolar tissue, while the complicated elements of the 
lost part, as it normally existed, (nerves, muscular fibres, 
glands, &c.) either do not occur at all, or at any rate much 
more sparingly than before : hence the new part can only im- 
perfectly fulfil the functions of its predecessor. 

2. Into tissues whose elements are not reparative, but 
directly increase the bulk of previously normal organs. Hyper- 
trophies — tumours. 

These may be distinguished by observing that in cases of 
hypertrophy, the newly formed parts are continuous with those 
previously existing, and cannot be anatomically distinguished 
from them. Hypertrophy may thus, in the same way as 
regeneration and on the same grounds, be divided into the 
true and perfect, or the false and imperfect. 

K 2 



132 



PATHOLOGICAL EPIGENESES. 



In tumours (in a restricted sense) the newly formed parts 
are not, as it were, fused into the older, as in hypertrophy, 
but are more or less separate and independent. This is, 
however, a mere artificial distinction between hypertrophy and 
tumour. 

All these distinctions are, however, of little service; we 
shall consequently leave them, and seek to resolve the indivi- 
dual epigeneses into their elementary phenomena. 

A classification of the different pathological epigeneses is very difficult 
in consequence of the various relations in which they stand to each other, 
and of their frequent transitions from one form into another. In accor- 
dance with the point of view from which we establish our observation 
will either the one or the other mode of arrangement be preferred. The 
surest basement for pathological anatomy is a sound acquaintance with 
histology, and impressed with that feeling, I intend, in the following 
pages, to resolve the different morbid formations as completely as possi- 
ble into their elementary parts, to consider these first in relation to 
themselves alone, and then as occurring united in large masses (tumours) 
and thus from that which is simple, to proceed to that which is com- 
pound. The connexion between the different pathological epigeneses 
and the relations in which they stand to each other will be afterwards 
considered. 



PUS. 



133 



CHAPTER V. 

PATHOLOGICAL EPIGENESES CONSISTING OF FLUIDS WITH MORE OR 
LESS ORGANIZED PARTS. 

PUS* 

The term pus, in the sense in which it is commonly used, 
conveys with it no very definite idea. We apply it to almost 
every creamy, white or yellow fluid, occurring in almost any 
part of the body, the only necessary assumption being that its 
formation is dependant on a morbid process. On more closely 
examining this class of fluids, we find that they often present 
very considerable differences, partly as regards their mode of 
formation, and partly as regards their microscopical and che- 
mical relations. Thus diffluent encephaloid and tubercle are 
frequently regarded as pus, indeed, even normal structures, such 

* The literature of pus is very abundant. The following are the 
most important recent works and memoirs on the subject : Th. Gluge, 
Observationes nonnullas microsc. fila (quae primitiva dicunt in inflammat. 
spect. Berol. 1835; Gueterbock, de Pure et Granulatione, Berolini, 
1837; Wood, de Puris Natura atque Formatione, Berolini, 1837; 
J. Vogel, iiber Eiter, Eiterung und die damit verwandten Vorgange, 
Erlangen, 1838 ; Henle, iiber Schleim- und Eiterbildung. Hufeland 
Journ. f. d. pract. Heilk. vol. lxxxvi. p. 5 ; Gluge, anatom.-mikrosk. 
Untersuchungen, Minden, 1838, p. 15, &c. ; L. Mandl, Anatomie 
microsc. Livr. 2. Pus et Mucus, Paris, 1839; Gruby, Observationes 
microscop. Vindob. 1840. F. E. Braun, der Eiter, &c, Kitzingen, 
1841; Messerschmidt, de Pure et Sanie, Lipsise, 1842; E. v. Bibra, 
Chemische Untersuchungen verschiedener Eiterarten, Berlin, 1842. 
Lehmann und Messerschmidt, iiber Eiter und Geschwure ; Archiv f* 
physiol. Heilk. v. B. Roser u. C. A. Wunderlich, vol. i. p. 220, &c. ; 
F. Biihlmann, Beitr. zur Kenntniss der kranken Schleimhaut der Respi- 
rationsorgane, Bern, 1843; Henle, Zeitschrift fur rationelle Medicin 
von Henle u. PfeufFer, vol. n. p. 177, &c. 



134 



PATHOLOGICAL EPIGENESES. 



as epithelium cells which have been rubbed off and formed a 
sort of emulsion with a fluid, have often from their purulent 
appearance and from the omission of accurate observation 
been mistaken for pus. Hence the necessity for dividing fluids 
which appear purulent into true genuine pus, and into spurious 
or false pus. 

But even true pus presents many differences in the form 
and properties of its corpuscles, in the proportions of the 
corpuscles to the fluid portion, &c. Hence genuine pus 
must be divided into many varieties, which it is necessary that 
we should know and be able to distinguish, if we hope to 
have a clear understanding of the variations presented by 
the process of suppuration in different cases. 

1. TRUE GENUINE PUS. 

Normal pus (pus bonum et laudabile) is that which is 
yielded by healthy-looking wounds healing by suppuration, 
and by mature abscesses. This is the best adapted for show- 
ing the properties of perfectly formed pus as well as the 
mode in which it is produced. 

Normal pus forms a creamy, thick, opaque and homoge- 
neous fluid, containing no flocculent matter, depositing on 
standing no caseous, grumous precipitate, and communi- 
cating a soft and fatty feeling when rubbed between the 
fingers. It has a faint yellow, and sometimes a white or 
faintly green tint, and develops, as long as it remains warm, 
a peculiar, mawkish animal odour, which it loses on cooling. 
It is somewhat sweet, and insipid, and has a specific gravity 
of 1030—1033. 

Normal pus consists essentially of two distinct parts, of very 
minute organized particles — the pus-corpuscles, and of a 
colourless aqueous fluid — the serum or liquor puris in which 
the pus-corpuscles are suspended as in an emulsion. 

The pus-corpuscles are quite invisible to the naked eye, 
and we can only begin to distinguish them by a magnifying 



PUS. 



135 



linear power of 50 — 100 ; but in order to study with accuracy 
their properties and structure, they should be magnified 200 
— 400 diameters. 

Their form is in general spherical,^ and is regular in pro- 
portion as the pus assumes a normal character. Sometimes 
they are irregularly rounded, elongated, oval, or rugged ; and 
generally speaking, they are irregular in proportion as the 
pus deviates from the normal type. Their diameter varies 
from the 200th to the 300th of a line ; it seldom exceeds the 
150th or falls below the 400th. These fluctuations in size are 
apparently dependant on the individual from whom the pus is 
obtained, or on the nature of the disease ; sometimes we 
find that all, or the greater number of pus-corpuscles from an 
abscess or wound are small ; in other cases that they are all 
large. 

In some cases the pus-corpuscles are very delicate, pale and 
transparent, and their surface smooth and even ;f but more 
commonly they are opaque, tough, uneven and granulated, 
that is to say, studded with very minute particles from the 
1000th to the 1500th of a line in diameter.J 

When observed separately, they appear colourless ; in heaps, 
they exhibit a yellow tint. They are only slightly elastic, but 
very soft, and under the compressor are reduced to an amor- 
phous magma. They are specifically denser than the serum, 
and gradually fall to the bottom. 

Many deviations of the corpuscles from the normal form will be de- 
scribed in our observations on abnormal pus. 

The corpuscles of genuine pus are organized forms, for the 
most part of a cellular nature, with a nucleus, cell-wall, and 
contents. 

The cellular structure with a decided nucleus, appears only 

* Plate in. fig. 1 and 2. t Plate in. fig. 11, a. 

t Plate in. fig. 1. 



136 



PATHOLOGICAL EPIGENESES. 



in unchanged pus-corpuscles, when the cell-wall is very thin 
and transparent. # In the majority of cases, the nucleus is 
covered by the granulated opaque cell-wall,f and does not 
become visible till the latter is dissolved or rendered transpa- 
rent by acetic acid .J In other cases, in which the develop- 
ment of the pus- corpuscle is imperfect, we see only the nucleus 
and no cell- wall. § 

The nucleus does not lie in the centre of the pus-corpuscle, 
but as is the case with all cells, is situated eccentrically, and 
is usually attached to the inner surface of the cell-wall. We 
may convince ourselves of this by allowing pus -corpuscles to 
float and rotate in the field of the microscope. || It is only the 
larger nuclei that form an exception to this rule, for they are 
sometimes so large as to occupy the whole space of the pus- 
cell. The nucleus of the pus-corpuscle presents many pecu- 
liarities, and is so different from other nuclei, as to require a 
somewhat careful consideration. 

In other cells the nucleus is a simple body, but in the pus- 
corpuscle this is not always, or indeed generally the case ; it 
is usually composed of several (2 — 5) minute granules forming 
a composite multiple nucleus. Sometimes on treating fresh 
pus-corpuscles with acetic acid, or a solution of salt, a single 
nucleus becomes apparent, indented like a trefoil leaf, or 
cloven into 2 — 4 smaller nuclei.^ But it is not every 
nucleus that undergoes this change ; in some cases it appears 
to resist the action of these reagents. The single large 
pus-corpuscles with a diameter of the 100th to the 80th 
of a line, exhibit several (two, three or four) such nuclei, each 
of which is composed of smaller bodies insoluble in acetic 
acid. 

The corpuscles which form the nucleus, when, by the addi- 



* Plate in. fig. 2, b, and fig. 11, a. 
t Plate in. fig. 3. 
II Plate in. fig. 11, a. 



t Plate in. fig. 1. 

§ Plate in, fig. 7, a, b. 

1| Henle, fig. 8—12. 



PUS. 



137 



tion of acetic acid, they are clearly brought before us, present 
various forms ; sometimes (generally in good pus) they are 
elliptic, and present an excavated cup-like form, resembling 
fresh blood-corpuscles ; # sometimes, however, they present a 
spherical or oval appearance.f In some cases they are dis- 
tinct from each other, even lying in different parts of the 
cell- cavity ; but they are more frequently in apposition, and 
joined together, so as to present the figure of a trefoil leaf, or 
some other form. 

This composite character of the nucleus in the majority 
of the corpuscles, as revealed by the action of acetic acid, is 
very characteristic of normal pus. The only other instances in 
which this occurs are in young gland-cells, and in the most 
recent layers of pavement epithelium, but in these cases they 
are never so general as in pus. Hence it follows that the 
size of the nucleus is liable to great deviations ; from being 
entirely absent it may occupy the whole cell. Its usual limits 
are the 800th to the 400th of a line. Nucleoli are rarely 
found in the nuclei of pus-corpuscles. 

I shall show further on, that the granules which remain after treating 
pus-corpuscles with alkalies or borax, and which MesserschmidtJ con- 
siders as nucleoli, cannot be regarded in that light, since they occur as 
much out of the nucleus as within it. If some writers altogether deny the 
existence of nuclei, or have seen them otherwise than as we have de- 
scribed, it must arise from imperfect observations, or from the circum- 
stance that normal pus was not examined. The above differences in the 
nuclei are connected with their chemical composition, and with diffe- 
rences in the mode of formation of the pus- corpuscles. I shall again 
return to this subject and attempt to elucidate it. 

The cell-wall of the pus-corpuscle varies in thickness, and 
surrounds the nucleus more or less closely. In delicate 
and young pus-corpuscles, it is very thin, smooth, membra- 
nous and transparent : in older and many peculiar sorts 



* Plate in. fig. 3 ; fig. 9, b. f Plate m. fig. 6, a. 

X Op. cit. p. 8—10. 



138 



PATHOLOGICAL EPIGENESES. 



of pus, it is thick, tough, opaque, and studded with minute 
granules. In many cases, pus-corpuscles have no definite or 
distinct cell-wall, consisting merely of a nucleus, and an irre- 
gular deposition around it, without any clearly definite out- 
line, as may be shown not merely from microscopic investi- 
gation, but by their relation towards endosmosis. This is 
especially the case with young imperfectly formed pus- 
corpuscles. 

Moreover, there are many differences in the contents of the 
cell occurring between the cell-wall and the nucleus. In 
pus-corpuscles with a single nucleus, a well-marked mem- 
branous cell- wall, and consequently a cavity between them, # 
we often find no solid body in the cell-cavity, excepting the 
nucleus. The contents must therefore be fluid, and doubtless 
identical with the serum of the pus, containing dissolved 
albumen ; for the corpuscles are rendered turbid and opaque 
by reagents which coagulate that substance. In other cases, 
in addition to the nucleus, granular contents are seen, with 
independent chemical reactions. Sometimes the contents 
seem as it were so thoroughly fused into the cell-wall, that 
the two form only a single substance, a solid but soft mass 
in which the nucleus is imbedded. 

Endosmotic and chemical relations of the pus-corpuscles. 
When either solid or fluid substances are allowed to react on 
pus-corpuscles, numerous changes, dependant on two diffe- 
rent causes, are observed to take place. One of these causes 
is the endosmotic activity of the pus-corpuscle itself ; the other 
is the chemical action of the reagents on the various mate- 
rials entering into the composition of the pus-corpuscle. 
Generally speaking, both forces are simultaneously in action ; 
we shall, however, consider them separately, in order to deter- 
mine with greater accuracy the effect of each individual 
reagent. 

When pus-corpuscles are submitted to the action of fluids, 



* Plate in. fig. 11a. 



PUS. 



139 



very deficient in solid constituents, they imbibe water by 
endosmosis, and become tumid. Conversely very concen- 
trated saline solutions, or dried hygroscopic substances, such 
as chloride of sodium, sugar, or chloride of calcium, have 
just the opposite effect ; they withdraw water from the pus- 
corpuscles, and cause them to contract. The former of these 
processes being termed endosmosis ; the latter, which only 
differs in the opposite direction of the current, is for the 
sake of distinction named exosmosis. 

The changes produced in the pus-corpuscles by endos- 
mosis are most obvious when they are placed in contact with 
distilled water : they then swell, become larger, and assume 
a spherical shape ; in most cases the distended cell-wall becomes 
more transparent, and the nucleus more obvious, the nuclei 
retaining for some time their cupped appearance. By pro- 
longed action, those cells with a perfect wall increase until 
they ultimately burst, on which the regular form of the exter- 
nal contour disappears, and the corpuscles assume an irregular 
ragged appearance. By further prolonged action the nucleus 
imbibes moisture, and its individual portions lose their 
cupped form, and become spherical. Some corpuscles present 
exceptions to the reaction ; they swell to a less degree, and 
the capsule is not distended to actual bursting. This is the 
case with those that possess no regular cell-wall, but consist 
merely of an irregular, badly defined precipitate around the 
nucleus. In this case, however, the nucleus becomes 
changed. 

To observe the phenomena of exosmosis, the pus-corpuscles 
must be placed in a concentrated solution of common salt, 
or else dried salt must be added to the pus : the corpuscles 
then assume a contracted appearance, and present a plicated 
and clear outline. Generally they become considerably 
smaller; pus-corpuscles whose diameter was the 200th of 
a line, afterwards do not measure more than from the 300th 
to the 400th of the same measure. Others are not so much 
affected, especially those which possess no regular cell- 



140 



PATHOLOGICAL EPIGENESES. 



the addition of water, the pus- corpuscles reassume their origi- 
nal form and character. 

Many chemical reagents produce a modifying effect 
on pus-corpuscles ; but when they are applied in a very 
dilute or very concentrated state, they combine the action of 
endosmosis or exosmosis with their own peculiar chemical 
reactions. We shall here give merely the most important 
reactions, those namely which elucidate the chemical compo- 
sition of the pus-corpuscles. # 

Dilute acids render the substance of the capsule transpa- 
rent, and burst it by endosmosis, but do not, even by pro- 
longed action altogether dissolve it. They cause the nucleus 
to stand clearly out, and for that purpose, dilute acetic acid 
is the best reagent. Moderately dilute solutions of most of 
the neutral salts, as of hydrochlorate of ammonia, chloride of 
sodium, or nitrate of potash gradually dissolve the substance of 
the capsule and the greater part of the contents, with the 
exception of the nucleus, and even this they render tumid, 
so that it loses its shape and outline, and forms an indefinite 
mass. 

Solutions of the alkaline carbonates and borax, convert 
the pus-corpuscles into a viscid mass, and the same effect is 
more rapidly induced by the caustic alkalies. Both capsules 
and nuclei disappear and there remain only very minute, 
dark molecules, with a diameter less than the 1000th of a 
line. Lehmann and Messerschmidt regard these molecules 
as nucleoli ; I cannot, however, accept this opinion uncondi- 
tionally, since they are scattered among the half-dissolved 
pus -corpuscles without any definite order; and further, since 
they are sometimes absent in pus-corpuscles with undoubted 
nuclei, and are present in other abnormal pus-corpuscles in 
which no nuclei are apparent; and lastly, since they are 



* A full and very accurate account of these reactions is given by Leh- 
mann and Messerschmidt. Op. cit. p. 226. 



PUS. 



141 



found in the serum, altogether independent of the pus- 
corpuscles. 

Substances which coagulate fluid albumen, such as metal- 
lic salts, tincture of iodine, alcohol, &c, render the pus- 
corpuscles opaque, a sign that they are infiltrated with an 
albuminous fluid. 

Saliva, mucus, urine, blood, and other animal fluids, do 
not as a general rule produce any very essential change in the 
pus-corpuscles ; bile, however, seems to break them up, pos- 
sibly in consequence of its containing soda. 

Boiled with concentrated hydrochloric acid, pus-corpuscles 
react in the same manner as the protein-compounds, forming 
a violet coloured fluid. 

From these reactions we may conclude that pus-corpuscles 
consist of several substances differing in their chemical cha- 
racters, and we can distinguish : 

1 . The substance of the capsule, which is soluble in solutions 
of the caustic alkalies and their carbonates, of borax, and for 
the greater part, in saline solutions, as those of hydrochlorate 
of ammonia, nitrate of potash, &c, and in part soluble in 
dilute acids, as acetic acid. It forms the wall and a portion 
of the contents of the cell, and is doubtless a protein-com- 
pound, very similar to, and probably identical with that 
modification of albumen which is precipitable by water, and 
is again dissolved on the addition of neutral salts or acetic 
acid. # 

2. The substance of the nucleus, insoluble in acetic acid, 
swelling in saline solutions, and dissolving in solutions of 
borax, the caustic alkalies and their carbonates. This like- 
wise is a protein-compound, and is probably identical with 
the modified form of coagulated fibrin which swells in a 
saline solution. f 

3. The substance of which the minute molecules consist, 

* Lehmann and Messerschmidt's a fibrin, 
f Lehmann and Messerschmidt's b fibrin. 



142 



PATHOLOGICAL EPIGENESES. 



which remain undissolved on treating pus-corpuscles with 
solutions of the caustic alkalies and borax. They are regarded 
by Lehmann and Messerschmidt as nucleoli, and in some 
cases probably this may be the true explanation, but they 
certainly also occur within the cell, but at the same time 
externally to the nucleus. 

Lehmann and Messerschmidt regard this substance as a 
protein-compound analogous to keratin, and in many cases 
this is doubtless true. Sometimes, however, these molecules 
consist of fat ; they are then soluble in ether, and if the pus- 
corpuscles are boiled in that menstruum, before the addition of 
the alkali, they do not make their appearance. 

Many kinds of " pus bonum" contain nothing corpuscular 
besides pus-corpuscles; others, on the contrary, contain 
minute rounded molecules,* often in very considerable quan- 
tity. They are always very minute, for the most part less 
than the 1000th of a line in diameter, and swim either alone 
or in heaps in the serum and between the pus- corpuscles 
which are frequently studded with them. These molecules 
present great differences in their signification and chemical 
constitutions ; sometimes they are protein-compounds analo- 
gous to the substance of the capsule, of the nucleus, or of 
the molecules insoluble in alkalies — elementary granules and 
partially-developed or abortive pus-corpuscles. In other cases 
they consist of fat. Finally, there are sometimes infusoria 
present, minute monades and vibriones, especially in pus from 
foul ulcers. As long as the animalcules are alive, we then 
observe an active motion, and I have sometimes been ena- 
bled, by feeding them with carmine, to bring into view the 
minute spots representing their stomachs. 

Moreover, we sometimes find accidental admixtures in 
healthy pus, some of which may be easily distinguished by 
the microscope, as epithelial cells or fragments of epidermis, 
crystals of cholesterin or of ammoniaco-magnesian phosphate, 

* Plate in. fig. 1, b. 



PUS. 



143 



and flocculi of amorphous or semi-organized fibrinous exu- 
dations. 

The liquor pur is, or serous fluid, in which the corpuscles 
swim, may be separated by allowing thin pus to stand for 
some time in a high and narrow glass ; the pus-corpuscles 
then gradually sink to the bottom, while in the upper part of 
the glass there is pure serum. 

This fluid is identical both in its physical and chemical 
characters with the serum of the blood : it is an aqueous 
solution of albumen, extractive matters, various salts, and 
fat. 

The qualitative composition of this serum is tolerably 
constant, but the quantities of the different ingredients vary 
considerably, as we have already seen to be the case with the 
dropsical effusions. It is upon these slight differences in the 
chemical composition of the serum that the varying action 
of pus on vegetable colouring matters is dependant. If 
the alkaline carbonates (?) or basic phosphates predominate, 
the pus has an alkaline reaction, as is usually the case w 7 ith 
fresh and good pus. Subsequently an acid (lactic ?) is deve- 
loped in it, which first renders its reaction neutral and then 
acid. 

The serum of pus occasionally contains a viscid matter, 
which may be distinguished by its being precipitated by acetic 
acid and by alum. It was first described by Giiterbock, 
under the term pyin, and regarded by him as characteristic 
of pus. This is not the case : pyin rarely occurs in good, and 
more frequently in abnormal pus ; it likewise occurs in other 
morbid products, as for instance, in carcinoma ; and even at 
the present time too little is known regarding its properties 
and chemical composition to allow of its being known by a 
definite name. 

Taking a comprehensive view of the quantitative analyses of 
pus, it appears in essential points to coincide with the plasma 
of the blood, or fluid of fibrinous dropsy. There is only 
this difference, that a portion of the protein- compounds which 



144 



PATHOLOGICAL EPIGENESES. 



are dissolved in the latter, exist in pus in a coagulated state, 
forming the pus-corpuscles. 

I give below a few analyses of pus, selected at random,* and by then- 
side, for the purpose of comparison, I likewise place the composition of 
the plasma of the blood. 



1000 parts contained : 





Blood-plasma 


l 


2 


3 


4 


Water . 


. 906 


902 


907 


862 


769 


Corpuscles (fibrin) 
Fluid albumen . 


3.4^ 
• 7 ? j 


> 80.4 60 


63 


91 


180 


Extractive matter 


3 




20 


29 


19 


Salts 


8 


13 


(6) 


(9) 


(9) 


Fat 


3 


25 


9 


12 


24 




1000 


1000 


999 


994 


992 



1. Was taken from a small-pox pustule and analyzed by Lassaigne. 

2. Was taken from an abscess in the neck and analyzed by 
v. Bibra, op. cit. p. 41. 

3. Was taken from an abscess beneath the breast and analyzed, by 
v. Bibra, op. cit. p. 96. 

4. Was taken from an abscess in the cheek, v. Bibra. op. cit. p. 27. 

Hence it is obvious that the analyses of the blood-plasma, and of pus 
may present great variations without destroying the analogy which 
subsists between them. The conversion of the blood-plasma into pus 
always occupies a certain time, during which it is exposed to all the 
modifying influences of metamorphosis and endosmosis, to which must 
be added that a considerable evaporation of fluid takes place from sup- 
purating surfaces. Hence pus is usually more concentrated, and con- 
tains less water than the plasma from which it is formed. 

Formation of pus. The formation of pus is dependant on 
two very distinct circumstances. In the first place, a fluid 
must be secreted or separated to act as a cytoblastema ; and 
secondly, the pus-corpuscles must be formed in and from 
this cytoblastema. The latter follows the general laws 
regulating organic development. 

The cytoblastema of pus is always the fibrinous fluid which 
has already been described in our observations on fibrinous 

* Numerous analyses of pus will be found in the works quoted in the 
note in p. 133, especially in the Treatise of v. Bibra. 



PUS. 



145 



dropsy. Consequently the formation of pus must invariably 
be preceded by the exudation of a modified blood-plasma. 

The opinion that healthy pus can be produced from the tissues of the 
body by their decomposition or solution, is at the present day unworthy 
of a serious refutation. That broken up fragments of tissue may be 
contained in abnormal pus will be presently shown. It appears certain 
that pus cannot be formed from a merely serous fluid containing no 
fibrin, like that of serous dropsy. Moreover extravasated blood can 
only act as a cytoblastema for pus, in so far as it contains plasma. 

The formation of pus-corpuscles from the cytoblastema 
does not take place in a very uniform manner ; it occurs in 
one way when the plasma remains fluid, in another when the 
fibrin coagulates previously to the formation of pus. 

The process of the formation of pus from a fluid cytoblas- 
tema can be best observed in fresh wounds cleansed from 
blood. In examining the fluid secretion from a wound, we 
first observe minute granules, less than the 1000th of a line 
in diameter, which are chemically identical with the mole- 
cules insoluble in the alkalies and in borax. There then 
appear, partly around these molecules, and partly indepen- 
dent of them, somewhat larger corpuscles, soluble in the 
alkalies, but not in acetic acid, identical with the nuclei of 
the pus-corpuscles. These nuclei appear sometimes isolated, 
sometimes in groups of twos or threes,^ thus forming compo- 
site nuclei ; around these the cell-wall is subsequently deve- 
loped, first appearing as a pale transparent membrane,f and 
subsequently becoming thickened and granular ; and thus the 
pus-corpuscle is formed. The production of pus-corpuscles in 
this manner is tolerably rapid ; in the course of three or four 
hours after the first appearance of the nuclei perfect corpus- 
cles may frequently be seen ; in other cases the process is 
slower. 

If the above observations describe the general type of the 
formation of pus in a fluid blastema, there are in special cases 

* Plate in. fig. 6, a, b. 
VOL. I. 



t Plate in. fig. 11, a. 
L 



146 



PATHOLOGICAL EPIGENESES. 



many exceptions which show that nature does not always 
strictly adhere to the same models, but induced, as it were, 
by new requirements, permits of many exceptions. The 
nucleus of the pus-corpuscle sometimes contains a molecule, 
which must be regarded as a nucleolus ; in other cases this is 
absent. The nucleoli do not here, at any rate, play the part 
which has been assigned to them ; they appear to serve 
merely as the most favourable points for the formation of the 
nucleus, in the same manner as an urinary calculus, for 
instance, is formed by deposition around a nucleus : they are, 
however, not essential to the formation of the nucleus. Nuclei 
are invariably formed in healthy pus : hence they may be 
regarded as essential to perfect pus-corpuscles ; but they are 
sometimes single, sometimes double, treble, or even quadru- 
ple, and their individual parts present almost innumerable 
differences in relation to size, form and arrangement. The 
differences are perhaps the most marked in the formation of 
the cell- wall and contents. Sometimes the formation proceeds 
in entire accordance with the scheme laid down by Schwann : 
we observe a simple and apparently vesicular nucleus placed 
eccentrically in a transparent, elastic, and round cell- wall: 
with a well-defined external contour. The nucleus, contents, 
and cell-wall are all destined to undergo, at a subsequent period, 
further simultaneous metamorphoses. In other cases, as we 
have already observed, there is only a nucleus, and an inde- 
finite, granular, amorphous precipitate around it, without a 
clear outer circumference, and, as its behaviour in relation to 
endosmosis shows, without a surrounding cell- wall. I have 
sometimes found in an isolated, very large pus-corpuscle (one 
sixtieth to one eightieth of a line in diameter) three or four 
separate nuclei, each of whichj on the addition of acetic acid, 
falls into two or three distinct portions. Around these several 
nuclei only a single cell-wall is formed. In pus-corpuscles 
the nucleus is, however, always formed previously to the cell- 
wall. 

We are not at present in a condition to state with certainty 



PUS. 



147 



what are the causes leading to these differences in the forma- 
tion of the pus-corpuscle. 

Let us now throw a glance on the chemical process occur- 
ring in suppuration, Lehmann and Messerschmidt* have made 
an attempt to explain it. In the first place molecular gra- 
nules become separated from the fluid plasma. These may 
consist of a peculiar protein-compound, or of fat, are of no 
very great importance in the normal formation of pus (since 
in healthy pus they frequently do not amount to one hun- 
dredth of the mass of the corpuscles) and very often are not 
converted into true pus-corpuscles. The nuclei are then 
formed, which doubtless consist of coagulated fibrin. Whether 
the capsules of the pus-corpuscles are likewise composed of 
coagulated fibrin, or whether as Lehmann and Messerschmidt 
assume, they are formed from the albumen of the plasma, is a 
point which I shall leave undecided. With our present defi- 
cient knowledge of the protein-compounds we can merely 
offer conjectures. At all events the tw T o following points 
may be regarded as established. Firstly, pus-corpuscles can- 
not be formed from albumen alone. Secondly, after the full 
development of the pus-corpuscles, the amount of fibrin in the 
plasma is exhausted, and the remaining serum of the pus 
resembles the serum of the blood, or the fluid of serous 
dropsy. 

The latter point was placed beyond all doubt by a case of empyema, 
which I observed three years ago at Munich. It is the case referred to 
in p. 47, and the composition of the fluid is given in analysis 3. The 
fluid discharged by the two first operations of paracentesis contained 
fibrin in solution, and in a short time coagulated. On the third occasion 
it no longer contained fibrin, but, on the other hand, pus- corpuscles. 
A few days after the last operation the patient died. On dissection it 
was found that the pleural cavity was completely invested with a thick 
pseudo-membrane, which was already half-organized, and must there- 
fore at all events have existed several days previous to death. The pus 
could therefore only be formed in the fluid ; but since the fluid which 



* Op. cit. p. 247. 

L 2 



148 



PATHOLOGICAL EPIGENESES. 



was first discharged contained fibrin, it is clear that this constituent was 
not originally absent, but was doubtless consumed in the formation of 
pus. 

Pus formed in this manner from a fluid cytoblastema is of 
frequent occurrence in the human body. We observe it in 
the suppuration consequent on wounds, on the external skin 
after burns or the application of blisters, in fibrinous dropsy 
into serous cavities, in pleuritis and peritonitis with exuda- 
tion, and on mucous membranes, as in catarrhs, bronchitis, 
gonorrhoea, and many other analogous cases. This mode of 
formation is frequently combined with that which is now to 
be described, when the fibrin has in part coagulated previous to 
suppuration. Pus discharged externally usually exhibits in 
these cases, perfect corpuscles ; there are frequently, however, 
seen amongst them, imperfect ones of an earlier development, 
and indeed in some cases, when the pus has been rapidly 
discharged before its corpuscles can be completely developed, it 
contains little more than nuclei without any external cap- 
sule. # 

The mode in which pus-corpuscles are formed from a solid 
cytoblastema of coagulated fibrin is somewhat different from 
the above. In this case, changes take place in the plasma 
identical with those described in the section on fibrinous 
dropsy, which accompany the coagulation of the dissolved 
fibrin. In the coagulated fibrin, and from it alone are the 
pus- corpuscles formed. The process of development is here 
much more difficult to observe than in the fluid cytoblastema. 
We seldom perceive the corpuscles till they are altogether 
formed ; they then appear enclosed in a stroma of amorphous 
or indefinitely fibrous fibrin.f By acetic acid the stroma 
becomes transparent and invisible ; the capsules of the pus- 
corpuscles likewise disappear, and their nuclei become appa- 
rent. The mode of formation is very probably the same as 
that already described. At first the pus-corpuscles are scan- 

* Plate in. fig. 6, and its explanation. f Plate in. fig. 5. 



PUS. 



149 



tily dispersed over the stroma ; subsequently, however, they 
become more abundant, and ultimately occupy the whole 
stroma, being separated from each other by intervening serum; 
finally the solid portions of fibrin disappear, and the whole of 
that constituent is converted into fluid pus. 

In this manner pus is formed in all abscesses in which the 
softening is dependant on the coagulated fibrin changing into 
fluid pus : in this manner it is formed in solid exudations 
from the pleura or peritoneum, in gray hepatization of the 
lung, and in a hundred similar cases. It frequently hap- 
pens that this mode of formation is combined with the pre- 
ceding, so that some of the corpuscles are formed from the 
coagulated, others from the fluid portion of the fibrin. 
In this or some other w T ay, pus may be formed from exuded 
blood, as the daily experience of surgeons teaches, and the 
experiments of Gendrin and others demonstrate. 

It does not always happen that pus produced in the latter 
manner is perfectly formed when discharged from abscesses, 
&c. ; it frequently contains flocculi of coagulated fibrin, which 
indicate no change, or merely an incipient conversion into 
pus. These have been termed " ventriculi puris" (Eiter- 
pfrbpfe)* We sometimes observe them forming a viscid 
mass (pyin ?) in which are imbedded perfect and distinct pus- 
corpuscles. 

It is scarcely necessary to observe that most of the opinions that have 
been promulgated regarding the formation of pus are undeserving of a 
serious refutation ; as, for instance, the view maintained by Gendrin that 
pus-corpuscles are nothing more than modified blood-corpuscles. In 
fact they have required no refutation since the works of Wood, Giiter- 
bock, myself, Henle, Valentin, Gluge, &c, have opened a new path 
in the theory of the formation of pus. During the last few years Gen- 
drin's ideas on the subject have been revived by Braun, v. Bibra, and 
Barry, but unsupported on any new grounds. I consider it unnecessary 
to state, in this place, all the points which are adverse to this opinion, 
for one is sufficiently convincing : namely, that the above described mode 



* See Ascherson in Casper's Wochenschr. 1837. No. 46. 



150 



PATHOLOGICAL EPIGENESES. 



of formation of pus-corpuscles from a fluid cytoblastema has been 
directly observed, whilst on the other hand, no one has ever yet suc- 
ceeded in following under the microscope the conversion of blood- into 
pus- corpuscles. Other objections to this view may be found in the 
above-named works on pus, and in Henle.* Another opinion to which 
I have already alluded, namely, that pus- corpuscles are modified epithe- 
lium cells, was promulgated at a time when we had no knowledge of 
the general laws of cell-formations, and knew very little even of the 
epithelium. This view, like the opinion of Gerber and Valentin, that 
pus-corpuscles are formed by the higher development or retrograde for- 
mation of the so-termed exudation- corpuscles, rests more on the inter- 
pretation than on the morphological development of the structure. 
We shall have occasion to revert to the exudation- corpuscles at the 
end of our section on pus. 

Diagnosis of normal pus. The recognition of this morbid 
fluid is apparently so easy that any one after once seeing it, 
and observing the above physical properties, would trust him- 
self to distinguish whether or not a fluid was actually pus : 
and yet there are numerous sources of deception. Fluids con- 
taining fragments of epithelium-cells in suspension may 
readily be mistaken for pus, and in examining the body after 
death, we sometimes believe that we have discovered suppu- 
ration, where in fact no morbid process had been going on. 
The examination of the fluid by the microscope is the best, and, 
indeed, the only certain means of guarding against such 
deceptions. If this instrument reveals the presence of normal 
pus-corpuscles, and on the addition of acetic acid, the charac- 
teristic nuclei appear, f then we may be sure that we have 
been examining pus, and normal pus. 

As I have repeatedly witnessed the above deceptions, I will by way 
of warning mention two cases. A woman died from pleuritis, with con- 
siderable purulent exudation into the pleural cavity. On examination I 
likewise found in the pelvis of the kidney, and in the ureter on each side 
a whitish-yellow, thick, creamy fluid, which had all the physical characters 

* Henle und Pfeufer, Zeitschrift fur rationelle Medizin, vol. n. 
p. 202. 

t Plate in. fig. 1—3. 



PUS. 



151 



of pus, and was mistaken for that fluid by the physicians who were 
present. As during life there were no symptoms of disease of the kid- 
neys, and as dissection did not reveal any morbid change in these 
organs, the case was regarded as a demonstration of the resorption of 
pus, and of its subsequent removal by the kidneys. 1 examined this 
assumed pus microscopically, and found in it no trace of pus-corpuscles, 
but merely broken cylindrical and pavement epithelium* from the 
pelvis of the kidney and the ureter. In another case in which 
the patient died from peritonitis with exudation, the stomach and 
upper part of the intestinal canal were perfectly free from remnants 
of food and chyle, but contained a large quantity of a thick yellow 
fluid, which was mistaken for pus. In this case also the microscope 
showed that the fluid contained no pus- corpuscles, but merely the 
cylindrical epithelium of the intestinal canal. 

Formerly great importance was attached to the distinctions between 
pus and mucus, and numerous pus-tests were published, which at 
present possess merely an historical value. They were based for the most 
part on the chemical relations of the pus- corpuscles towards various 
reagents. In addition to many which were founded on no sure princi- 
ple,-]- we may mention the following. GrasmeyerJ treated diluted pus 
with carbonate of potash. The mixture became converted by prolonged 
stirring into a thick viscid gelatinous mass, capable of being drawn out 
in threads. Caustic ammonia acts in a similar manner (Donne's test). 
Both alkalies cause the pus -corpuscles to swell and gradually to dis- 
solve into a viscid mass. These pus-tests explain a peculiar change 
which pus sometimes undergoes in the body, especially when mixed 
with urine. When, in disease of the bladder, alkaline urine containing a 
large quantity of carbonate of ammonia is mixed with pus, the pus- 
corpuscles undergo the same change in the bladder from the alkaline 
reaction of the fluid contained in it as they do in the preceding pus- 
tests ; they become converted into a viscid mass which physicians often 
mistake for mucus, thus altogether losing sight of its true signification. 
Gruithuisen's§ pus-test was founded on false premises ; he supposed 
that pus and mucus during decomposition contained different forms of 
infusoria. Moreover, Guterbock's|| test, based on the circumstance that 
pus being fatty burned with a clearer flame than mucus, is of no practical 

* Plate in. fig. 4. 

f Compare J. Vogel, Untersuch. iiber Eiter, &c. p. 96, &c. 

X Abhdlg. v. Eiter u. d. Mitteln ihn von ahnlichen Feuchtigkeiten zu 
unterscheiden, 1790. 

§ Naturhist. Unters. iiber den Untersch. zw. Eiter und Schleim, 
1809. 

|| Op. cit. 



152 



PATHOLOGICAL EPIGENESES. 



use. The microscope renders all these chemical pus- tests superfluous ; 
it enables us not merely to distinguish pus from mucus, broken epithe- 
lium, blood, &c, but likewise to determine approximately the amount 
of these different substances, which chemical analysis has never suc- 
ceeded in doing. It is only in a few cases that no certain conclusions 
can be deduced from microscopic examination. We sometimes find in 
normal mucus, that is to say, in the product of the secretion of healthy 
mucous membranes, isolated corpuscles, similar to those of pus ; they 
are termed mucus-corpuscles and are probably epithelium- cells in a very 
early stage of development. When we find these corpuscles in the 
secretion of a mucous membrane, it is difficult to distinguish them from 
a small number of pus-corpuscles ; but in all these doubtful cases a very 
accurate diagnosis is of no importance, for if amongst millions of epi- 
thelium-cells, we do find a few pus-corpuscles, so slight a process of 
suppuration is unimportant to the physician. By the help of the 
microscope we can not only distinguish pus from the normal fluids of 
the body, but also good pus from that which presents an unhealthy 
appearance, from ichor, or from the detritus of encephaloid or tuber- 
cular masses, as will subsequently be showm 

ABNORMAL PUS. 

We have hitherto described pus in its ordinary normal 
characters. The deviations from this type, are, however, so 
numerous and distinct, that a whole series of slight, hardly 
appreciable changes might be given, at one extreme scarcely 
differing from normal pus, at the other there being a fluid so 
different in its characters from pus, as no longer to deserve 
its name. These deviations are dependant on various 
causes. 

a. On the admixture of foreign ingredients. 

Blood may be mixed with pus. On opening an abscess 
some blood often gets mixed with it, forming red streaks or 
flocculi in which undoubted blood-corpuscles can be recognized. 
Or if the pus is formed in consequence of a contusion, or of 
extravasation, the mixture of blood with it is much more 
intimate. Here the effused blood acts as the cytoblastema 
for the formation of pus-corpuscles, and the blood-corpuscles 
are more or less injured or dissolved ; indeed, they often 
entirely disappear. In addition to the more or less perfect 



PUS. 



153 



pus-corpuscles we observe an indeterminate, grumous, and 
often reddish-brown mass. This pus is impure. 

Mucus is often mixed with pus in suppuration of the 
mucous membranes : it then contains mucin which renders it 
tenacious and capable of being drawn out in threads, in addi- 
tion to epithelium-cells, and other substances of accidental 
occurrence. On the addition of acetic acid the mucus coagu- 
lates, entangling the nuclei of the dissolving pus-corpus- 
cles^ Moreover, pus from abscesses without containing any of 
the secreted products of the mucous membranes, sometimes 
appears tenacious and stringy, its serum containing a viscid 
substance in solution, which is coagulable by acetic acid and 
alum (pyin ?) .f Moreover, the cells of the epidermis or of 
glands, flocculi, and crystals of cholesterin or of ammoniaco- 
magnesian phosphate, are not unfrequently mixed with 
pus.j 

b. On changes in the structural portion of the pus itself, 
malformations of the pus-corpuscles, fyc. The pus-corpuscles 
sometimes differ more or less from their normal type, losing 
their regular rounded form, and becoming angular or club- 
shaped.§ The nuclei also frequently appear changed. || 
Sometimes, on the addition of acetic acid, no nuclei make 
their appearance, (being apparently entirely absent), and we 
observe only the minute molecules which are noticed after 
treating pus with alkalies or a solution of borax.^f In many 
cases the quantity of the granular molecules, which consist 
either of modified protein-compounds or of fat, appears to be 
increased in the pus, and sometimes, from the simultaneous 
deficiency of pus-corpuscles, it would seem as if these 
granules had taken their place, being either broken up or 
abortive corpuscles. These modified conditions of pus 

* Plate in. fig. 6, b. 

f Plate in. fig. 11, and its explanation. 

X Plate in. fig. 8 and 9. § Plate in. fig. 7 and 10. 

|| Plate in. fig. 10, d. f Plate in. fig. 7, b. 



154 



PATHOLOGICAL EPIGENESES. 



appear in numberless forms; they occur in unhealthy 
suppuration, in abscesses, in gouty and scrofulous persons, 
&c. 

c. On the diminution of the corpuscles in relation to the 
serum. Formation of ichor. Pure ichor contains no corpuscles, 
but is a fluid of a reddish or brown-red colour and a more or 
less sickly odour. It is the serum of the blood coloured by 
the pigment of the dissolved corpuscles, but frequently con- 
tains, mixed with it, the detritus of various textures. A 
perfect formation of ichor entirely prevents suppuration, being 
a consequence of the decomposition of the blood, and the 
death of a portion of the body (gangrene). Both processes, 
however, frequently occur together and their products become 
mixed. 

These modifications of true pus form an uninterrupted 
series, ultimately extending to morbid fluids hardly deserving 
the name of pus. Of these we shall now speak. 

I select the following, by way of illustration, out of the large number 
of instances of abnormal pus and ichor which I have had the opportu- 
nity of examining. They may perhaps serve to show the mode of 
examining and describing such cases. For other cases see the explana- 
tion of Plate in. The abdominal cavity of a woman who died from 
peritonitis with exudation, contained several pounds of a thin yellowdsh 
white fluid, in which were soft flocculi, varying from the size of a lentil 
to that of plum- stone. It had a faintly alkaline reaction, and after 
standing for some hours separated into a yellow sediment, and a super- 
natant colourless serum. The reactions of this serum were precisely 
those of the fluid of serous dropsy. The sediment contained minute 
granules, which in the irregularity of their form and size differed essen- 
tially from normal pus- corpuscles. They were of a somewhat indefinite 
roundish form with rough angular points, and in size they varied from 
the 400th to the 150th of a line. On treating them with acetic acid, 
there were no decided indications of nuclei : under the prolonged action of 
that reagent they almost totally disappeared, nothing being left but very 
minute dark granules, about the 1000th of a line in diameter. These 
molecules were very unequally distributed amongst the corpuscles, some 
containing none, others three or four. An aqueous solution of borax, 
allowed to act for some time, produced no material change in the corpus- 
cles. The larger flocculi were very soft, of a yellowish white colour, 



SPURIOUS PUS, 



155 



and consisted of an aggregation of the same corpuscles, sometimes 
arranged in a definite manner, sometimes in an amorphous mass. 

Pure ichor from a vesicle on the gangrenous arm of a typhus -patient, 
was a perfectly clear fluid of a reddish colour, and to the eye resembled 
light red wine. It had an alkaline reaction, and under the microscope, 
no solid bodies — neither blood- nor pus -corpuscles — could be detected in 
it. It coagulated on the application of heat. In 1000 parts there were 
obtained by evaporation 60 of solid residue, consisting of albumen with 
some saline constituents. This fluid was therefore the serum of the 
blood coloured by dissolved hsematin. 

A woman with ascites frequently underwent the operation of paracen- 
tesis ; and finally the canula was allowed to remain, in hopes of exciting 
adhesive inflammation. The fluid which then escaped was brownish- 
grey turbid ichor, of a cadaverous odour. Under the microscope, no pus- 
corpuscles could be detected, but there was an indefinite granular matter 
similar to that which is thrown down on the addition of corrosive sub- 
limate or an acid to a fluid containing albumen in solution. This gra- 
nular matter was insoluble in acetic acid, ammonia, and potash, and was 
not even rendered gelatinous by the alkalies. It appeared to be a protein- 
compound, since it dissolved in boiling concentrated hydrochloric acid, 
forming a violet coloured liquid. 

2. SPURIOUS PUS. 

The abnormal sorts of pus which we have described form 
a gradual transition-series to other morbid fluids which have 
usually been included under the general name of pus, but 
are formed in a perfectly different manner, namely by the 
breaking up and liquefaction of distinct morbid products, such 
as tubercle, encephaloid, scirrhus, &c. These products will 
be described in a future page, and their distinctions from 
pus clearly indicated. 

In the present section we must describe certain granular 
forms, which are sometimes found in true pus between the 
corpuscles, and sometimes occur alone in serum, forming an 
apparently purulent fluid. In form they present many diffe- 
rences, and their mode of production, and their signification is 
by no means invariable. They were first described by Gluge, 
who termed them compound inflammatory globules ; to me, 
the term granular cells appears more appropriate, since their 



156 



PATHOLOGICAL EPIGENESES. 



connexion with the inflammatory process is not more intimate 
than that of various other organized formations occurring in 
exuded fluids, and they are formed under conditions in which 
there is very little probability of their resulting from inflam- 
mation, as for instance, in cysts in the thyroid gland. 

When these granular cells occur in a perfect condition, 
they vary in diameter from the 200th to the 80th of a line ; 
some of them are perfectly round, others oblong, irregular 
and even angular. At first sight they appear as an agglo- 
meration of minute granules, varying in diameter from the 
800th to the 1000th of a line. By refracted light they 
appear dark, of a brown or blackish colour ; # by reflected 
light, white. These granular cells are not affected by water ; 
if exposed to the prolonged action of acetic acid or ammonia, 
they separate into the individual granules of which they are 
composed. Caustic potash and ether sometimes, but not 
always, dissolve these granules. 

From my own observations I should say that the forma- 
tion of these granular cells is best observed in inflamed lungs, 
where it appears to occur in the following manner. 
Cells with a nucleus and a nucleolus, differing from pus- 
corpuscles in their larger size (the 200th to the 1 00th of a 
line) and in having a single nucleus, are formed in the fluid 
or coagulated exudation (fibrinous dropsy). These become 
gradually filled with minute granules, which at first, when 
only few in number, readily admit of the nucleus being seen ; 
subsequently, however, they conceal it, and the originally 
smooth cell-membrane becomes rugged, the granular cell 
appearing as a spherical agglomeration of granules. Subse- 
quently the cell-wall appears to vanish, the enclosed granules 
to separate from one another and to fall into irregular heaps, 
and each individual granular cell to undergo, in a minute 
scale, the very same process which a mass of coagulated 
fibrin undergoes in its conversion into pus-corpuscles. 

* Plate in. figs. 13, 14 and 15. 



GRANULAR CELLS. 



157 



This view of the formation of granular cells is confirmed by Bennett.* 
According to Gluge,f they are formed by the adherence of the nuclei of 
dissolved blood- corpuscles : but the nucleus of the human blood- corpus- 
cle is itself of doubtful existence, and I have sometimes observed the 
development of these cells, as distinctly as, considering the difficulties of 
the case, could be expected. 

From their chemical relations the granules appear to consist partly of 
fat, soluble in ether, partly of a modification of protein similar to the 
molecular granules of normal pus, insoluble in the alkalies and in borax, 
and partly of salts of lime (the carbonate and phosphate). I am con- 
vinced that the true granular cells are formed from cells which as a 
general rule first appear pale in colour, containing a nucleus, and with 
fluid homogeneous contents, which subsequently become granular. It 
is true, that this process cannot be directly observed ; I have, however, 
seen in very many cases where these granular cells were present, that 
when the development was not very far advanced, there were undoubted 
cells without any or with only a few granules ; J that when the development 
was somewhat further advanced, the cells appeared for the most part, 
or entirely filled with granules ;§ and finally, that when the development 
was perfect, they formed irregular granular heaps and scattered gra- 
nules. || The whole course of events in that form of pulmonary hepati- 
zation which does not proceed to suppuration, but disappears by resolu- 
tion, confirms the above view. It is true that in this case, we have only 
the opportunity of instituting microscopic observations, when the patient 
is carried off by some other disease during the stage of resolution ; I 
have, however, met with several such cases. Here we observe in the 
first place, that so long as the mass remains firm, there are only a few 
granules, but numerous undoubted cells ; as development progresses, 
the cells diminish and the granules increase in number, and finally, after 
perfect softening, there are fewer cells and fewer granular heaps ; the 
latter being broken up into separate granules. Some observers, espe- 
cially Henle and Bruch,^[ have declared themselves against my view 
regarding the mode of formation of granular cells, but still I cannot help 



* Pathological and Histological Researches on Inflammation of the 
Nervous Centres, in the Edinburgh Medical and Surgical Journal. Oct. 
1842, and April 1843. 

f Anat. Mikrosk. Unters. p. 12, et seq. 

X Plate in. fig. 12. § Plate in. fig. 13. 

|| Plate in. fig. 14. 

% Das kornige Pigment der Wirbelthiere, p. 18. 



158 



PATHOLOGICAL EPIGENESES. 



firmly maintaining the correctness of the above description, at least with 
reference to some of the forms. Their reasons are for the most part 
theoretical, and founded merely on analogy, and may be refuted by a 
similar mode of argument. Theoretically, it is not more improbable 
that granules should be formed from a fluid in the cavity of a cell, than 
that they should be formed from a fluid not enclosed within a cell. We 
observe, however, similar processes in most vegetable cells. Moreover, 
in encephaloid and scirrhus, cells at first perfectly homogeneous become 
afterwards filled with granules. Hence, for this mode of formation also, 
there is no lack of analogies. On the other hand I will not deny that 
occasionally the mode of formation may be reversed, namely, that isolated 
elementary granules may be first produced, which subsequently collect 
into groups, and finally become invested with a cell- membrane. Indeed, 
I believe that I have sometimes observed this process, that I have seen 
the accumulated granules gradually invested with a membrane, and 
granular cells or very similar forms produced. This I have witnessed in 
expectoration. 

There is also a third case of frequent occurrence. There arise in the 
solid or fluid cytoblastema, elementary granules, which either remain 
single or accumulate into irregular heaps without any cellular formation. 
They entirely resemble the molecular granules which have been already 
noticed as frequent constituents of normal pus. Cases also frequently 
occur where exudations, without any trace of cellular formation, break 
up directly into these elementary granules. Practically, it is often hard 
to distinguish whether this process or the formation of granular cells 
has existed. The difficulty arises when there has been no opportunity 
of observing the development in its earlier stages, but when the final 
results alone are subjected to microscopic examination; these final 
results being the same in both cases. Yet as a sufficient number of 
cases have been observed, wherein on the one hand there is a mere 
distribution of the elementary granules without any trace of granular 
cells, and on the other, there are distinct granular cells without any 
isolated granules, we may consider ourselves well entitled to separate, 
theoretically, the two processes from each other. 

The diagnosis of granular cells is easy in those cases where they are 
perfectly formed and occur in large quantities. The granular bodies of 
the colostrum* have a close resemblance to them. But the constituent 
molecules here are of unequal size, and the entire corpuscles less regular 
than the true granular cells. In examining the fluid from an inflamed 
breast, the two may be confounded together, as I myself on one occa- 



* Plate in. fig. 16. 



SUPPURATION. 



159 



sion saw. With practice they will, however, be easily distinguished. 
Where imperfectly formed granular cells occur together with the ele- 
mentary granules previously described, the diagnosis of the individual 
corpuscles becomes almost impossible. 



Having thus described the morphological and chemical 
constitution of the different fluids embraced under the some- 
what general name of pus, we may now take a general view 
of the formative relations, and the pathological importance of 
these morbid products. 

Pathological anatomy has, in this respect, a much more 
difficult office than pathology, for the latter is able to follow 
the entire series of processes from their first appearance in the 
vascular system to the perfect formation of these products, 
and to consider them in their mutual relations ; whilst the 
former is often confined to the observation of results, which 
must be retraced with many interruptions and obscurities in 
the connecting links. I refer, therefore, for the completion 
of this fragmentary outline to my article on " Inflammation 
and its Results," # and to the rigidly critical development of 
inflammation and its results by Henle.f We shall return in 
a future page to the connection of these processes. 

Suppuration consists essentially in the fact that the parts 
of the exuded plasma capable of such formation, undergo a 
peculiar organization — an organization on which the cha- 
racter of pus is dependant, and which distinguishes it from 
other morbid products. When this capability of organization 
in the plasma is clearly manifested, true pus-corpuscles, 
or completely formed granular cells occur ; when it is less 
strongly declared, we observe either pus-corpuscles, or simply 
accumulations of elementary granules. These elementary 
types — true pus-corpuscles, abnormal pus-corpuscles, granu- 

* Wagner's Handworterbuch der Physiologic vol. i. 
f Zeitschrift f. rationelle Medicin, vol. ir. 



160 



PATHOLOGICAL EPIGENESES. 



lar cells and elementary granules — are, however, but the 
final results of a continuous morphological series, between 
which there exist an infinity of intermediate points. 

All these formations have a definite mode of development 
from which they never deviate ; they are capable of no higher 
stage of completion, that is to say, they are not in a mere 
transition- stage to a more perfect organism. From a pus- 
corpuscle or a granular cell nothing higher can be produced. 
Hence the importance of this formation to the organism. It 
is never permanent, but is removed either by internal resorp- 
tion, or by external rejection. 

When pus arises from a fluid blastema, then its formation 
hinders the coagulation of the fluid. But when pus arises 
from a solid blastema, that blastema itself becomes dissolved 
and rendered fluid by the formation of the pus, and thus its ex- 
ternal rejection becomes possible. The uses of the formation 
of pus to the organism consist in this, that by its means 
exudations which were originally fluid, and would have 
become solid, are prevented from coagulating; and those 
already coagulated again become fluid, and thus the condi- 
tions requisite for their removal are effected. The distinction 
between genuine suppuration and the formation of granular 
cells depends upon the way and manner in which the exuda- 
tion is removed. In genuine suppuration there is an effort to 
reject the fluid products externally. In pus forming upon 
membranes in free connexion with the external surface of the 
body, this discharge is directly effected, as on the mucous 
membranes and the external skin. When it occurs in en- 
closed portions of the body, as in the parenchyma of 
organs, this tendency to external rejection is not less remark- 
able. The pus collects in cavities, forming abscesses, and 
escapes either by seeking for itself an external outlet, or its 
evacuation is assisted by art. 

In the formation of granular cells the exudation is likewise 
rendered fluid. But the minute granules into which the 
granular cells at last break, are very much smaller than the 



SUPPURATION. 



161 



pus-corpuscles, and with them the tendency to external 
rejection is less strong : they are much more easily resorbed 
than pus-corpuscles. 

Hence genuine suppuration may be characterized as the 
liquefaction of an exudation with a tendency to external rejec- 
tion ; the formation of granular cells, as liquefaction with a 
tendency to resorption. This is, however, but an elemen- 
tary type of either process. Both may occur together, or 
either may be converted into the other. Thus, in many cases 
pus enclosed within the parenchyma of an organ may disap- 
pear without having been rejected externally ; its corpuscles 
breaking up and gradually becoming resorbed. But these are 
exceptions ; in the majority of cases the enclosed pus finds for 
itself a way by which it reaches the external surface, though 
its course may be a slow one, as in deep-seated abscesses, 
psoas abscesses, &c. Conversely, the formation of granu- 
lar cells may cause an abscess, especially in very tender and 
delicate organs. A frequent example of this is afforded in 
inflammatory softening of the brain. Hence it follows that 
the formation of granular cells is that form of suppurative 
process by which the organism is the most spared, and the 
same is the case with suppuration on free surfaces. When 
pus is formed in the parenchyma, especially when an abscess 
is produced, and the pus forcibly seeks to obtain an external 
outlet, there must be some destruction or injury of the 
organized parts. This injury or destruction is in different 
cases of very varying intensity. Thus, there is the healthy 
abscess, where the loss of substance is soon replaced, and the 
part shortly after the rejection of the pus returns to its pri- 
mitive condition; and there is the malignant phagedenic 
abscess or ulcer, where the loss of substance continually 
increases, and the ulcer gradually extends. 

In attempting to explain these processes we are led to inves- 
tigate the causes which give rise to the formation of pus, and 
the reasons why in some cases normal pus, in others granular 
cells, or abnormal pus are produced. 

VOL. I. M 



162 



PATHOLOGICAL EPIGENESES. 



Let us first consider the question — why does pus arise 
from exuded plasma? Does this arise naturally from the 
chemical properties of the exuded plasma, or is it dependant 
on external influences ? 

The exudation possesses in itself a certain tendency to the 
formation of organized products ; there are produced in it, inde- 
pendently of external influences, more or less perfect pus- 
corpuscles. In the case of empyema mentioned in page 147, 
pus was formed in a large quantity of fluid, which was 
excluded from all communication with the external parts of 
the body by a thick layer of fibrin. A very accurately per- 
formed experiment recently submitted by Dr. Helbert to our 
Physiological Institute, gave a singularly striking proof of this 
tendency. # Fresh plasma taken from beneath the cuticle 
raised by an ordinary blistering plaster, exhibited no corpus- 
cles of any kind. After standing in a glass for five or six 
hours, minute corpuscles were formed exactly analogous to 
those which appear in wounds when the formation of pus 
commences. Repeated experiments invariably gave the same 
results. Hence there was an incipient formation of pus even 
in plasma which was entirely separated from the body. 

On the other hand, it is a known fact that the formation of 
pus can be obstructed or promoted by the application of exter- 
nal means. The application of moist warmth promotes it ; of 
cold, retards or even prevents it. Further, it is certain that 
large quantities of exudation are most easily converted into 
pus, while small quantities are most liable to be converted 
into persistent tissues. Again, in individuals of vigorous con- 
stitution, and possessing that peculiar disposition of the 
nervous system in which the inflammatory process is 
especially intense and rapid, normal pus is easily formed, 
while in weak cachectic persons with feeble vital energy, 
and where there is a tendency to gangrene, and in persons 

* Helbert, de exanthematibus arte factis fragmenta. Gotting. 1 844, 
p. 16. See also the remarks in p. 84 of this volume. 



SUPPURATION. 



163 



with very torpid chronic diseases, there is a tendency to the 
formation of unhealthy pus. There is no doubt that in these 
cases certain chemical, physical, and vital influences, depen- 
dant upon the nervous system, and unknown to us, com- 
bine together; and through this multiplicity of conditions 
we are prevented from obtaining an exact and definite 
acquaintance with the acting causes. If a certain impulse is 
once given in directing the formative process, then the ela- 
borated product tends to sustain it, for fully developed pus, 
in the same manner as neighbouring healthy structures, 
excites a local tendency to the formation of a substance simi- 
lar to itself. This explains the old observation that pus 
makes pus, and that when an abscess is too early opened, 
perfect suppuration is delayed or prevented. 

The distinction between healthy and malignant suppuration 
admits of the following explanation. In healthy suppuration 
the formation of pus proceeds very rapidly ; in three or four 
hours after its effusion the exudation may be converted into 
pus ; although in many cases, the process requires three or four 
days for its completion. When the elementary textures of 
an organ are surrounded, and, as it were, enclosed by the 
coagulated exudation, so as to be excluded from the influence 
of the nerves, and to be deprived of the circulation of the 
blood, it is only by the conversion of the exudation into pus 
that their liberation is effected ; and, if this is accomplished 
sufficiently early, no destruction of tissue results. Again, 
normal pus is a bland substance, devoid of all deleterious pro- 
perties, and its constituents are analogous to those of the 
blood-plasma. Hence normal suppuration is not destructive 
to tissue, which is only affected mechanically, as by the 
collection of pus in an abscess causing local compression, or by 
the surrounding parts ultimately giving way. 

It is otherwise with malignant suppuration, the course of 
which is usually chronic, lasting for weeks, and even months 
before the exudation liquefies. Through this prolonged exclu- 
sion of the nerves and capillaries, the normal tissue becomes 

M 2 



164 



PATHOLOGICAL EPIGENESES. 



partially destroyed ; it dies away, breaks up, and its remains 
are thrown off with the pus which is at the same time formed. 
Further, there are dynamic causes which influence the for- 
mation of malignant pus, and simultaneously act upon the 
constituents of the parenchyma : in unhealthy suppuration, and 
when there is a tendency to gangrene, the histologic elements 
of the tissues are much more easily destroyed than in their 
normal condition. Finally, unhealthy pus frequently exerts 
a chemical action on the surrounding parts, sometimes con- 
taining free acids, carbonate of ammonia, or other consti- 
tuents which chemically exert an injurious effect.^ In this 
way malignant suppuration becomes immediately connected 
with those abnormal epigeneses, which under the names of 
tubercle, encephaloid, cancer, &c, form alike the terror of 
the physician and of the patient. We shall in a future page 
return to the consideration of these formations. 

But the process of suppuration stands also in the most 
intimate connection with healthy epigeneses, with the process 
of regeneration, and the formation of granulations ; of this also 
subsequently. 

With regard to the cause of the formation of granular 
cells, even less is known. I can here only repeat what I 
have already elsewhere observed respecting it.f It is observed 
principally in very composite organs — in the brain, the lungs, 
the liver, the spleen, the thyroid gland, &c, — and it occurs in 
those cases where the result of the exudation is most favour- 
# able, namely where resolution occurs. Sometimes, indeed, 
as in the brain, it leads to softening of the parenchyma. This 
formation appears to be carried on most favourably when the 
quantity of exudation is small, and its effusion is very gra- 
dual. 

In conclusion, we must offer a few remarks on the resorp- 

* According to Dumas, even hydrocyanic acid may be formed in the 
process of suppuration. Comptes rend. 1841, vol. xiii. p. 144. 
f Wagner's Handworterbuch d. Physiologic vol. i. p. 345, 355. 



RESORPTION OF PUS. 



165 



tion of pus and on what are termed metastatic abscesses. An 
actual resorption of pus can only occur when its corpuscles 
become liquefied and fluid. This process is, indeed, very 
rarely observed, and an extremely long time is requisite for it, 
since the fluids of the body in which the pus-corpuscles must 
be dissolved usually exert no great solvent power upon them. 
The resorption of pus often appears to occur in a com- 
paratively short period, for the serum of a fluctuating abscess 
becomes suddenly resorbed, causing the fluctuation and all 
physical signs of the presence of an abscess to disappear, 
while the pus-corpuscles, however, remain long uninjured, 
and are only very gradually resorbed. 

Frequently also the term " resorption of pus" is applied to 
the occurrence of pus in the circulating system. Pus, however, 
never occurs in the veins or lymphatics, in consequence of 
resorption through the uninjured vessels. It is either gene- 
rated in the veins themselves, or is admitted into them 
through openings caused by some injury. It is only the 
serum of pus which can be conveyed unchanged into the 
vessels by means of resorption ; this subject we shall again 
notice in the special part, when we treat of the vascular 
system. 

I have in the preceding part described four morphological elementary 
types of the corpuscles presented in pus — true pus-corpuscles, abnor- 
mal pus- corpuscles of irregular form, and without any, or with an irre- 
gular nucleus, granular cells, and elementary granules. All these 
structures are essentially distinct from those which occur in exudations 
developing permanent structures, and which will be treated of in the 
next section. The structures described by Henle and Gluge as inflam- 
matory globules, I regard partly as broken up granular cells, and partly 
as aggregated elementary granules ; and the name which they have 
adopted appears to me unsuitable, because all kinds of pus may be the 
product of inflammation just as much as these inflammatory globules, 
and further, because these sometimes occur under circumstances where 
no inflammation, at least in the common acceptation of the term, 
can have taken place. Valentin,* and with him some others, have 



* Repert. vol. in. p. 173. 



166 



PATHOLOGICAL EPIGENESES. 



distinguished the proper pus-corpuscles from the exudation- corpus- 
cles, which latter are of a whiter colour, and lie upon each other in a 
tessellated manner ; afterwards, however, according to them they assume 
a yellower tint, and are converted into pus- corpuscles (through the 
absorption of fat?). To me it appears unsuitable to designate pus- 
corpuscles in their early stages by a separate name ; but that other 
structures— cells already clearly characterized as of a different sort — can 
be converted into pus- corpuscles, I do not believe. At an earlier period, 
when I had chiefly considered the formation of pus upon mucous mem- 
branes, and at a time when the importance of cellular formation in its 
earliest stages was scarcely recognized, I did, indeed, believe in the 
possibility of the conversion of immature epithelium-cells into pus- 
corpuscles. Now I regard the formation of pus, as a peculiar product 
of the exudation which occurs immediately on the appearance of the 
first formative molecules ; and this leads me to believe that struc- 
tures intended for other objects cannot be converted into pus- corpuscles, 
and conversely, that pus- corpuscles can never be converted into the 
elements of a persistent tissue ; of the latter I am decidedly convinced. 
Millions of pus-corpuscles have been brought under the microscope 
before my eyes, but never have I perceived the least indication of a 
transition towards another structure. On the other hand, I have very 
often examined the earlier stages of the development of persistent tis- 
sues, in which cells do indeed appear, which an unpractised observer 
might confound with pus-corpuscles, but due examination shows an 
essential difference between them. After being subjected to acetic acid, 
they never show the nucleus with two, three, or four granules charac- 
teristic of pus- corpuscles, but merely a simple nucleus. I do not believe 
that such a cell can, by a retrograde metamorphosis, be converted into a 
pus- corpuscle. I am not acquainted with any case wherein the nucleus 
of a cell has experienced in its development so important a transforma- 
tion as that which is here assumed. One out of many similar examples 
that I might adduce will serve to prove this. Two dogs received at the 
same time flesh-wounds. After the lapse of twenty-four hours these 
were perfectly similar in appearance. There was little discharge, for 
the dogs as is usual, frequently licked the wounds. The fluid contained 
blood- corpuscles, and also very many round colourless corpuscles vary- 
ing in size from the 400th to the 300th of a line. They were smaller 
than the ordinary pus- corpuscles in dogs, but when treated with acetic 
acid, they showed the same composite nuclear structure, (containing 
2, 3, or 4 granules) as ordinary pus -corpuscles. Hence there can be 
no doubt that these were young pus -corpuscles. In addition to the 
flesh-wound, one of the dogs had received a small wound penetrating 
the abdominal cavity, into which a dilute solution of hydrosulphate of 
ammonia was injected. The animal seemed to suffer violent pain from 



SOLID EPIGENESES. 



167 



the injection, and was very ill for a quarter of an hour ; he then began 
to amend, and in forty- eight hours, when he had apparently quite 
recovered, was killed. The intestine was covered in several places with 
coagulated fibrinous exudation, which being examined with the micro- 
scope appeared to be partly amorphous, and partly to contain cells 
which were either fusiform or tolerably large round primary cells (from 
the 200th to the 100th of a line) with a single nucleus which was not 
affected by acetic acid; they were, therefore, entirely different from 
the above described rudimentary pus- corpuscles. The wound in the 
intestine was nearly closed, and exhibited thinly scattered granulations 
which contained pus-corpuscles with nuclei capable of being broken up 
by acetic acid, and perfectly similar to those above described. Since, 
however, the cells occurring in exudations are distinct from their very 
first origin, and we can distinguish between those which become pus- 
corpuscles and those which develope themselves into persistent tissues, 
it appears quite unnecessary to regard exudation- corpuscles as peculiar 
structures ; especially since there is no certain mark by which they can 
be distinguished from any other primary cells. If it were proposed to 
designate as exudation- corpuscles all those primary cellular forms 
which occur in exudations, and whose nature is not accurately deter- 
mined, the proceeding would be illusory, and more than that, superficial 
observers would run the risk of applying the name of exudation- corpus- 
cles to all cells occurring in exudations. On this last ground it appears 
to me that the name is particularly objectionable. Such an objection 
might not be sufficiently strong to cause the disuse of a name already 
established, but it is weighty enough to have its effect when new ones 
are to be adopted. 

SOLID PATHOLOGICAL EPIGENESES. 

Although the variety of forms exhibited by fluid morbid 
products is very considerable, this is still more strikingly the 
case with the solid epigeneses ; in order to facilitate the consi- 
deration of our subject we will divide it into two parts. The 
first of them embraces the elementary structures which occur 
in regeneration after the loss of tissue, and in hypertrophy. 
The second concerns the composite structures which are 
commonly designated by the name of tumours, and embraces 
partly the same elementary structures either singly or in com- 
bination, and partly also other distinct elements. 



168 



PATHOLOGICAL EPIGENESES. 



EPIGENESES OF THE ELEMENTARY TISSUES. 

Imperfectly organized structures. 

In dissections, it very frequently happens that solid epige- 
neses are found, which without belonging to the class of con- 
cretions, yet examined by the microscope offer no trace of 
organization. They are designated according to circumstances 
by various names, as solid exudation, coagulated lymph, fresh 
pseudo-membrane, and so forth. They are characterised by 
the fact, that under the microscope they appear perfectly 
amorphous ;* and when treated with acetic acid, ammonia, or 
potash, they become paler and more transparent, until at 
length, in some cases, they entirely disappear. In many cases 
they are mixed with granular elements — vesicles and granules 
of fat — which when treated with ether disappear ; or with protein- 
compounds in a granular state — elementary granules in which 
no decided cellular formation can be discerned.f This gra- 
nular appearance usually remains unchanged after the applica- 
tion of the above-named reagents. Solid epigeneses of this 
kind sometimes cover the surfaces of internal organs, as for 
instance of those parts which are invested with serous mem- 
branes, and sometimes they are deposited in the parenchyma, 
thickening the elementary textures, and thus giving rise to 
imperfect hypertrophies or tumours. They always exhibit a 
lardaceous appearance. Chemically they re-act like coagulated 
protein-compounds (fibrin) with a certain amount of fat, and 
more or less saturated with serum. They always arise from 
fibrinous dropsy, of which the fibrin has coagulated, and are 
to be regarded as solid cytoblastemata, whose further develop- 
ment was interrupted by the death of the organ which was 
attacked. Had the vitality of the organ been prolonged, 
they would, according to circumstances, have been changed 



* Plate ii. fig. 2, 



f Plate ii. fig. 3 and 5. 



EPIGENESIS OF AREOLAR TISSUE. 



169 



into the several kinds of epigeneses — into concretions, areolar 
tissue, fibrous tissue, pus, non-malignant or malignant tu- 
mours ; or they would have been resorbed. 

It is unnecessary to multiply examples* of these imperfectly organized 
epigeneses, since they are of extremely frequent occurrence, and are 
found without exception in all vascular parts of the body, in which 
fibrinous dropsy occurs. When they present themselves as isolated 
tumours, they are very frequently regarded as tubercle ; indeed, one 
half of the cases of supposed tubercle belong to this class. To this 
subject I shall have frequent occasion to refer in the special part of this 
work. These imperfectly organized epigeneses are of very frequent 
occurrence in the most dissimilar organs. With regard to the unprofi- 
table question, whether they are always the product of inflammation, I 
must refer to the section which treats of the pathological anatomy of that 
morbid process. 

EPIGENESIS OF AREOLAR TISSUE. 

The development of areolar tissue is one of the most 
common pathological epigeneses. It occurs in regeneration 
succeeding loss of tissue, in cicatrices, and in hypertrophy of 
those parts which in the normal condition consist principally 
of areolar tissue ; but also in independent tumours, and in 
short under the most variable conditions. Since areolar tissue 
enters into almost all organs, and is a constituent of most 
parts of the body, the frequency of its pathological develop- 
ment is the more easily understood, in accordance with the 
law of analogous formation, when it happens that in any part 
or from any cause an increased secretion of blastema takes 
place. The cytoblastema of this tissue is sometimes fluid ; 
sometimes solid. It is formed from a fluid cytoblastema in 
the healing of wounds by suppuration, in granulations, in the 
gradual hypertrophy of parts consisting principally of areolar 
tissue, in warts, condylomata, &c. Here the formation is 
gradual, and is supported by a long continued increased secre- 



* See the descriptions of fig. 2, 3 and 5, in Plate it. 



170 



PATHOLOGICAL EPIGENESES. 



tion of blood-plasma (the nutrient fluid) kept up by inflamma- 
tory irritation. The epigenesis of areolar tissue, and with it 
the increase of hypertrophy, continues so long as the secretion 
of the formative material continues augmented. It would 
appear, therefore, in its power to be unlimited, for such 
epigeneses as condylomata, warts, or the proud flesh of gra- 
nulations often attain a very considerable size. 

Again, areolar tissue is very frequently formed from a 
solid cytoblastema. In these cases the formative material is 
always the coagulated fibrin of fibrinous dropsy, as in false 
membranes on serous surfaces, as for instance in the peri- 
cardium, the pleura, or the peritoneum, or after inflam- 
matory induration of the subcutaneous cellular tissue. Hence 
this epigenesis is as a rule confined to the metamorphosis 
of the exuded and subsequently coagulated fibrin, and ceases 
w T hen this is perfectly converted into areolar tissue. 

Morphology of its development. Normal areolar tissue 
consists, as is well known, of fine transparent fibres, varying 
from the 2000th to the 1000th of a line in diameter; and 
the same is the case when it is pathologically reproduced. 
But, as in pathological structures generally, the product is 
frequently less perfect than the normal type, The individual 
fibres are not always so clearly separated from one another, 
being more or less fused into an amorphous cytoblastema ; 
the arrangement of the fibres in the mass, their division into 
fasciculi, &c, is less regular than in the normal areolar tissue. 
This is most especially the case when the formation is recent : 
very old morbid formations of areolar tissue, as adhesions, 
pseudo-ligaments, &c, usually consist of areolar tissue which 
in no respect differs histologically from the normal type. 
Also the nucleated fibres described by Henle, which are 
distinguished by their resisting the solvent action of acetic 
acid, are frequently found in larger or smaller quantities in 
newly formed pathological areolar tissue. 

The process of development is the same for morbid as for 
normal areolar tissue ; the fibres proceed from a more or less 



EPIGENESIS OF AREOLAR TISSUE. 



171 



distinct cellular origin. In the former case, there are formed 
in the cytoblastema nucleated primary cells, which are 
lengthened at both their ends, and assume a fusiform shape ; 
the extremities of these unite with one another, and there are 
thus formed long varicose fibres. 1 * From these caudate cells arise 
the fibres of areolar tissue ; a cell being either converted into a 
single fibref or else by assuming a grooved arrangement, and 
these grooves deepening, finally splitting into a bundle of fibres.j 
In other cases the process is less clearly indicated, and deviates 
more from the cellular type. We often observe in the cyto- 
blastema very pale gelatinous nuclei arranged lengthways in 
regular order, sometimes mixed with elementary granules, but 
not surrounded with clearly defined cell walls.§ From the 
blastema thus imperfectly converted into cells, the fibres are 
directly produced. 

In other cases the cells are indeed clearly defined, but irre- 
gularly and for the most part laterally fused together. || Some- 
times there are seen very pale, irregular and apparently non- 
nucleated cells : the nuclei are, however, not really absent, 
for after the application of acetic acid, they become clearly 
visible. In the nuclei we can usually, but not always observe 
nucleoli. From these statements it follows that, in idea, 
areolar tissue in its pathological epigenesis follows the cellular 
type, but that in some cases peculiar influences seem to throw 
the type very much in the back ground, if not entirely to 
obliterate it. This explains the variation in the statements of 
different observers, as for instance, Schwann and Henle, 
respecting the normal development of areolar tissue.^" Some- 

* Plate i. fig. 12 ; Plate iv. fig. 1, c, and 2, a ; Plate vn. fig. 3, b, e, 
4, D. 

f Plate vn. fig. 3, d, 4, d. 

X Plate iv. fig. 1, d, 2, b, c; Plate vn. fig. 4, c. 
§ Plate iv. fig. 1, a ; Plate vn. fig. 3, c. 
jj Plate iv. fig. 1, b. 

% Bischoff has collected the different opinions on this point in his 
Entwicklungsgesch, p. 452 = 



172 



PATHOLOGICAL EPIGENESES. 



times, indeed, the cellular formation is so obscure, that the 
most careful observer can discern no trace of nuclei or cells, 
and the fibres of areolar tissue would appear to spring imme- 
diately from an amorphous solid cytoblastema. It is neces- 
sary here to guard against confounding the indefinite fibrillse 
and lines which the coagulated fibrin, while yet undeveloped, 
sometimes exhibits,^ with the fibres of areolar tissue. 
Whether the nucleated fibres which here and there occur in 
morbidly formed areolar tissue, and which by their great 
thickness, their usually winding, or even spiral course, their 
occasional dichotomic separation, and their insolubility in acetic 
acid, are distinguished! from true areolar tissue and range 
themselves with elastic tissue — whether these, as Henle 
believes, arise from a prolongation and fusion of the nuclei, 
or whether they are to be regarded as another structure 
altogether distinct from areolar tissue, between whose elements 
they insert themselves — I will not venture to decide. 

A perusal of the descriptions of the plates will throw considerable 
light on the above remarks. I have made a large number of examina- 
tions (upwards of 50) respecting the pathological development of areolar 
tissue, partly on the human body, and partly on animals, after wounds, 
subcutaneous division of tendons, &c. They yielded the results which 
have been above described, and sometimes even more varied ones ; I 
have never been able to establish a general law that would explain why 
the cellular formation that accompanies this development is sometimes 
clearly and sometimes only indistinctly apparent. 

Chemistry of the development. Perfectly formed areolar 
tissue consists chemically of a gelatigenous substance (colla), 
while the cytoblastema consists of fibrin, as may be clearly 
demonstrated in those cases where areolar tissue arises from 
an exudation of coagulated fibrin. Fibrin and colla differ, 
however, from each other not only in their chemical proper- 
ties, but also in their elementary composition. In the deve- 

* Plate in. fig. 5. 

f Compare Henle, Allgem. Anat. Plate n. fig. 6, 7, 8. 



EPIGENESIS OF AREOLAR TISSUE. 



173 



lopraent, the morphological change must he simultaneously 
accompanied by a chemical change of the blastema ; this is 
first shown by the appearance of the nucleus, which differs 
chemically from the cell-membrane. This chemical change 
is not a sudden but a gradual one. This is seen in the fact 
that immature areolar tissue when boiled yields no gelatin ; 
and the same is the case with that of the foetus (Schwann), 
and with that of granulations and condylomata (G. Simon 
and Guterbock). On boiling this substance, both obtained a 
fluid which after nitration gave the same reaction as if pyiti 
were present. 

In my own investigations of recently formed, or forming 
areolar tissue, I have frequently found a fluid which coagu- 
lated on the addition of acetic acid, and therefore in this point 
of view resembled pyin. Hence we may presume that in the 
chemical changes which ensue, some of the elements of fibrin 
are thrown off and form pyin, whilst others are converted 
into colla. But the chemical properties of these substances 
are as yet too little known to admit of more than mere sup- 
position on these points. 

The above description is equally applicable to the morbid 
formation of fibrous tissue, of the fibres of tendon, and 
of other tissues, which histologically accord with areolar 
tissue. 

The time requisite for the formation of areolar tissue can- 
not be precisely determined. It is longer than that which is 
necessary for the formation of pus. Yet it is short in com- 
parison with that which appears to be required for the forma- 
tion of other organized structures. I believe from repeated 
observations that I am justified in concluding that from four 
to five days after the formation of the cytoblastema, fibres of 
areolar tissue may occur in it ; the formation, however, of 
large masses of this tissue appears to require at least one, and 
frequently several weeks. 

Gelatin, whose ultimate chemical composition is doubtless identical 
with that of areolar tissue, contains according to Mulder, 50.4£ C. 



174 



PATHOLOGICAL EPIGENESES. 



63.£ H, 18.0£N, 25.3£ O, while fibrin contains 54. 6£ C, 6.9£ H, 
15.7% N, 22.1-g- O with 0.7-g- S and P. Hence in the conversion of 
the latter into the former, carbon and hydrogen must be given off and 
oxygen added, while the nitrogen remains unchanged ; or nitrogen and 
oxygen added, and carbon and hydrogen removed. All attempts to 
determine these changes accurately by calculation must fail, and lead 
only to a useless sporting with formula with the semblance, but not the 
reality of exactness. We know far too little of the chemical composition, 
and especially the atomic weight of these organic substances to obtain 
from such attempts any certain results. These are the elementary 
relations of the above-mentioned epigenesis ; to enter more minutely 
into their varied modifications, would in the present place be super- 
fluous, since they will be frequently brought forward in the following 
pages. 

EPIGENESIS OF THE BLOOD AND VESSELS. 

Blood-vessels occur very frequently as pathological epige- 
neses in the restoration of lost parts, in granulations, in 
pseudo-membranes, in various hypertrophies, and in tumours. 
But our knowledge of the process of this development is still 
defective, especially since the normal formation of the blood- 
vessels in the embryo is only imperfectly understood. It has 
been much disputed whether new vessels occur simply as a 
prolongation or further development of the old, or whether 
they may be formed independently and without connection 
with the normal vessels.^ 

From a large number of observations, I believe myself 
justified in concluding that new vessels arise directly in the 
blastema, and only at a later period connect themselves with 
the previously existing normal vessels, indeed, that this is 
usually the case ; further, that not only the vessels themselves, 
but also their contents — the blood — can be produced anew 
in this manner. In support of this formative process the 
condition in the embryo may be adduced, where the blood, 
as well as the vessels, is formed from the common cytoblas- 

* See Hasse's Pathological Anatomy, English edition by Swaine, 
p. 192. 



EPIGENESIS OF THE BLOOD AND VESSELS. 175 

tema; it is supported also by direct observation. In the 
midst of newly formed substance, (inflammatory exudation, 
&c.) accumulations of blood-corpuscles surrounded with more 
or less clearly indicated walls without any connection with the 
normal vessels are observed. It is true that we might be 
easily deceived on this point, since extravasated blood, which 
might be mistaken for a new formation, is mixed with many 
exudations ; there remain, however, plenty of cases in which 
the attentive observer need be in no danger of being 
misled. 

According to my own observations* the process seems to 
be as follows : in an amorphous blastema (coagulated fibrin) 
red points are formed, which are commonly of a size sufficient 
to enable the observer to discern them with the naked eye. 
Under the microscope each point appears as a group of blood- 
corpuscles of various sizes, in form roundish, and without the 
central depression observable in perfect blood-corpuscles ; they 
have usually a clearly defined outline and a yellowish-red 
colour. Their diameter is generally something smaller than 
that of normal blood-corpuscles, being from the 600th to 450th 
of a line. I have never observed that newly formed blood- 
corpuscles in any pathological structure were (as is the case 
with the formation of blood in the embryo) greater than 
normal ones. They dissolve in water and acetic acid, with- 
out yielding any indication of nuclei: the groups of these 
blood-corpuscles have not at first a very distinct contour, but 
appear at the edges to merge into the surrounding exuda- 
tion ; their form is indefinite, roundish, elongated, or annu- 
lar. It is only after some time that these groups appear 
clearly distinct from the parenchyma ; they then throw off 
rays or branches of a defined form ; still, however, destitute of 
true walls.f Probably the walls of the vessels are formed 
around them at a later period, when areolar tissue, muscular 
tissue, and epithelium, in accordance with the general laws of 



* Plate v. fig. 1—4. 



f Plate v. fig. 4. 



176 



PATHOLOGICAL EPIGENESES. 



development, surround and inclose the ramifying masses of 
blood. When the new vessels are perfectly formed, the walls 
become distinctly visible ;* indeed, when subjected to the 
action of acetic acid, they exhibit a regular nucleated arrange- 
ment which manifestly appertains to the walls of the vessels 
and corresponds with the cells in the different layers of the 
wails.f The perfectly formed vessels, with their contents, 
enter earlier or later into communication with the original 
vessels in their neighbourhood, and then take a part in the 
general circulation. At the earlier periods of their existence 
the blood which they contain, although fluid, is motion- 
less. 

The vessels whose pathological epigenesis I have observed 
were all larger than capillary vessels : they were not formed 
from cells, as Schwann imagines to be the case with capillary 
vessels, neither were they formed in intercellular spaces ; for 
the formation of blood always took place very early, before 
the formation of any other cells, and even before the forma- 
tion of areolar tissue. It is, however, not improbable that 
in the formation of capillary vessels the process is as Schwann} 
describes it, namely, that in the first place ramifying groups 
of cells are formed which contain blood, and which opening 
into one another, form a net- work of vessels, so that the 
original cell-walls which enclosed the blood become the walls 
of the subsequently formed capillaries. 

There are two ways of explaining the formation of vessels from the 
original vascular trunks. Either some of the original trunks are rup- 
tured, and blood is effused from them, which channelling its way through 
the cytoblastema becomes subsequently enclosed within walls. But 
this is an explanation against which much may be alleged ; for it is not 
easy to see why the blood effused in the cytoblastenia should not be 
equally distributed, instead of confining itself in certain ramifying 
courses, and finally again discharging itself into other normal vessels. 



* Plate in. fig. 5. 

f See Plate in. fig. 7, 8, 9, of Henle's Allgem. Anat. 
t Mikrosk. Unters. Plate x. fig. 12. 



EPIGENESIS OF BLOOD AND VESSELS. 



177 



On the contrary it is not very probable that extrava sated masses of 
blood, can, in the like manner, as newly formed blood become surrounded 
with regular walls. This much, however, is certain, that extravasated 
blood cannot always give rise in this manner to the formation of new 
vessels ; it may, indeed, suffer many other modifications, as has been 
already mentioned, and will be often again noticed, On the other side 
it may be supposed that in accordance with the law of analogous forma- 
tion, there arise from the normal vessels, walls, which are at first 
altogether closed, but which afterwards communicate with them, and 
receive blood from them. This process would differ from the former 
only in this, that here the vessels are formed without their usual contents 
(blood). Future experience must decide whether any thing of this kind 
actually occurs. 

What are the causes of the epigenesis of blood and vessels ? 
It may be supposed that here also the law of analogous for- 
mation plays a part, since the influence of the normal blood- 
vessels calls forth this process of formation from the exuda- 
tion ; in fact we find that this epigenesis of vessels is not only 
of most common occurrence in highly vascular parts, as, for 
instance, upon the skin, but is also most frequent under those 
circumstances where the vessels are most replete with blood 
and where hyper eemia exists, as for instance in granulations. 
Whether the extravasation of blood facilitates the epigenesis 
of vessels must remain yet undecided. We must at all events 
acknowledge that the true causes of this epigenesis still remain 
in much obscurity. 

Sometimes the epigenesis of vessels only become apparent 
when the previously invisible capillaries become enlarged, 
receive more blood, and thereby become visible to the naked 
eye. This is the case in hyperemia of most parts of the body, 
at least of such as are superficial, and can be observed during 
life, as for example the conjunctiva of the eye. The time 
requisite for the epigenesis of blood and of vessels appears to be 
very short in proportion to that required for the development 
of other epigeneses. I have myself seen blood arise in an 
exudation within forty-eight hours after its effusion. Home 
observed numerous vessels formed within the course of twcnty- 

VOL. I. N 



178 



PATHOLOGICAL EPIGENESES. 



nine hours. Usually, however, a much longer time is 
required for its formation. 

The chemical relations of this epigenesis are very imper- 
fectly understood; in the formation of vessels, the same 
chemical forces are doubtless exerted as in the formation of 
areolar tissue, of elastic tissue, and of simple muscular tissue ; 
that is the protein-compounds of the blastema become con- 
verted, partly into a substance yielding gelatin, and partly into 
other substances, with whose chemical composition we are 
still more ignorant. With respect to the chemistry of the 
formation of blood there is not the least difficulty in account- 
ing for the production of the blood-plasma from the exuded 
fluid ; both being in fact identical. Moreover there is no 
difficulty in supposing that the globulin of the blood-corpus- 
cles is formed from the protein-compounds of the exudation, 
although it has not yet been artificially procured. The for- 
mation of the hsematin is equally obscure in this case, and in 
the ordinary formation of blood. 

EPIGENESIS OF EPITHELIUM AND EPIDERMIS. 

The epidermis, as well as most forms of epithelium, as for 
instance the pavement epithelium consisting of several layers, 
exhibits in the normal condition a continuous epigenesis on 
the one hand, and a continuous destruction on the other. On 
the surface which is turned to the subjacent cutis or mucous 
membrane, new cells are continually forming from the blas- 
tema afforded by the vessels of the subjacent membrane; 
these become further developed, undergo the ordinary changes, 
and at length having arrived at the surface, are gradually 
rubbed off and removed. 

A precisely similar process takes place when these forma- 
tions, after being destroyed by any morbid cause, are repro- 
duced — the most frequent class of all pathological epigeneses. 
In a case of this nature so long as any inflammatory irritation 
is present, the cytoblastema afforded by the vessels of the 



GRANULATIONS. 



179 



subjacent membrane becomes converted into pus. Usually 
as this irritation decreases the formation of pus ceases, and in 
its place there is the production of epidermic or epithelial cells 
which follow the same process in their development as is 
observed in their normal formation. An identical law of for- 
mation is pursued when the epithelium or epidermis becomes 
thickened, or when epithelium is pathologically formed where 
in normal circumstances it does not exist, as for example, in 
encysted tumours ; the cyst on its inner surface being very 
generally invested with epithelium.* The chemical like the 
morphological relations of development in all these cases pre- 
cisely follow the normal type. 

GRANULATIONS, f 

In the preceding sections the epigeneses of areolar tissue, 
of vessels, and of epithelial structures have been considered as 
so many isolated processes. Cases are, however, frequently 
observed where all these formations are combined, where they 
simultaneously occur at one and the same part of the organism 
from the same cytoblastema, and are usually accompanied 
with suppuration. Such complicated epigeneses are usually 
distinguished by the term granulations. They occur under 
extremely various circumstances — in suppurating wounds, on 
the surfaces of serous membranes, in abscesses, fistulse and so 
forth. They are produced by the simultaneous formation of 
areolar tissue, vessels, and pus, from a solid, or more com- 
monly fluid blastema. The physical and histological charac- 
ters of granulations vary in accordance with the preponderance 

* Plate v. fig. 6. Plate ix. fig. 2. 

f Compare Henle in Hufeland's Journal, vol. lxxxvi. p. 56 ; Travers 
on Inflammation, London, 1844, p. 110, &c. ; Giiterbock, de pure et 
granulatione ; and the principal works on Inflammation, as those of 
Hunter, John Thomson, Allen Thomson, Kaltenbrunner, &c. Liston 
has published a description (with instructive plates) of the formation of 
new vessels in granulations. Medico-chirurg. Transactions, 1840, 
p. 85, &c, Plate i. 

N 2 



180 



PATHOLOGICAL EPIEGNESES. 



of one or other of these products, and according to the degree 
of development in which they occur. When the vascular 
formation predominates, they appear of a blood-red; when 
there is a paucity of vessels, they are of a pale colour ; when 
the areolar tissue prevails, they are firm ; when the blastema 
remains amorphous, they have a lardaceous appearance; 
when it contains a large number of pus-corpuscles, they are 
soft and spongy. Hence granulations, when examined under 
the microscope, sometimes exhibit numerous blood-corpus- 
cles, (the walls of the vessels being seldom clearly indicated, 
but sometimes becoming so on the addition of acetic acid,) 
sometimes numerous pus-corpuscles, sometimes a perfectly 
amorphous mass, sometimes areolar tissue in various stages 
of development, and sometimes all these elements together ; 
they generally contain a fluid which coagulates on the addi- 
tion of acetic acid (pyin) . Granulations represent a transition 
state. They are an epigenesis in the act of development. 
In proportion as the granulations become further developed, 
the formation of pus disappears, and the cytoblastema becomes 
more and more changed by the formation of areolar tissue, 
vessels, and sometimes also of other elements, as cartilaginous 
and osseous tissue, simple muscular fibre, &c. and at last they 
form a solid persistent epigenesis. They occur both on the 
external and internal free surfaces of the body, and finally 
become invested with epithelium or epidermis. Beyond this 
stage of their progression, they are no longer termed granu- 
lations, but receive names corresponding with their future 
relations. 

Since granulations in most cases contain vessels which are usually in 
a state of hyperemia and consequently give rise to an effusion of fibri- 
nous fluid, they supply the cytoblastema requisite for further develop- 
ment. And since a portion of the blastema is converted into pus, we 
can understand why granulations secrete pus ; but the formation of pus 
is not necessarily associated with the presence of granulations. 



EPIGENESIS OF FAT. 



181 



EPIGENESIS OF FAT AND ADIPOSE TISSUB. 

Fat occurs in the normal body under very different con- 
ditions. It is present as adipose tissue, when cells with an 
amorphous cell-wall contain fluid fat; as fat-globules, or 
granules (the latter being usually very minute) in many 
fluids ; and as dissolved or imbibed fat. 

There are as many, and, indeed, greater differences in those 
fats which result from a pathological epigenesis. Those of 
most common occurrence are morbidly formed adipose tissue, 
as in fatty hypertrophy (the fatty dropsy, or polysarkia of 
some writers) ; abnormal adipose tissue, as in the fatty dege- 
neration of many organs, for example, of the muscles and the 
kidneys ; independent fatty tumours, which either consist 
entirely of fatty tissue, as lipoma, or of a union of that with 
areolar tissue, forming steatoma. All these formations are 
characterized by the fat being enclosed in peculiar cells (fat- 
cells), which more or less resemble those of normal adipose 
tissue.* These fat-cells sometimes (especially when cold) 
contain crystalline depositions of margarin.f In other cases, 
the newly formed fat occurs free, in larger or smaller vesicles, 
which are usually so minute, that they can only be recog- 
nized with the microscope. They may be distinguished by 
the peculiar manner in which they refract light, and by their 
solubility in ether. These fat-globules occur either free 
amongst other histologic elements, as, for instance, between 
the hepatic cells in many forms of fatty liver; between 
the different coats in obliterated vessels ; in the substance 
of encephaloid ; and in certain fluids, as in blood, pus, 
&c. ; or, they are found in the interior of cells, as in 
those of the liver. J Where these accumulations of fat do 
not occur as distinct globules, but infiltrate the tissues 



* Plate vii. fig. 1. t Plate x. fig. 3. 

\ Plate i. fig ix. 



182 



PATHOLOGICAL EPIGENESES. 



of the body, they are then recognizable by chemical ana- 
lysis rather than by the microscope. Depositions of fatty 
granules occur under the same circumstances as those of fat- 
globules ; in fact the two are usually associated, and the latter 
are only distinguished by containing chiefly solid fat — mar- 
garin, cholesterin, and serolin — whilst the former consist of 
fluid fat (olein). The fatty granules are for the most part 
small (elementary granules) ; sometimes single, sometimes in 
groups, and forming various kinds of aggregate corpuscles 
and granular cells, and often deposited in very considerable 
quantity. They must not be confounded with the elementary 
granules arising from the protein-compounds which occur 
under similar circumstances, but differ from fat-granules 
by their insolubility in ether. Many deposits of fat assume 
a crystalline arrangement; thus, margarin and margaric 
acid form acicular crystals united in tufts and stars, # while 
cholesterin forms rhomboid tablets.! Pathological depo- 
sitions of fat form the transition between organized and 
unorganized epigeneses ; whilst newly formed adipose 
tissue must be regarded as truly organized, crystalline de- 
positions of fat must undoubtedly be regarded as concre- 
tions. 

The horny scales described by Valentine]: and Gerber§ are doubtless 
crystals of cholesterin; so, also, in all probability are the rectangular 
tablets described and depicted in several places by Gluge. 

The causes, morphology, and chemistry of the develop- 
ment of these products present very great differences. The 
question concerning the ultimate causes of this formation of 
fat is connected with the still imperfectly understood theory 
of nutrition, and this brings us to the much disputed subject 

* Plate x. fig. 3. f Plate x. fig. 1. 

I Repertorium. 1837. p. 265. 

§ General Anatomy of Man and the Mammalia. English Edition, 
by Gulliver, London, 1842, p. 136. 



EPIGENESIS OF FAT, 



183 



respecting the formation of fat from the food, which we shall 
not at present consider, in consequence of the undecided 
state in which it remains. Very probably, in all cases where 
fat is produced, not only the cytoblastema, but also the blood 
from which it is derived, is more than usually abundant in 
fat. We often, indeed, meet with fat occurring as fat-glo- 
bules and granules in many amorphous blastemata ; this fat 
remains, whilst the rest of the blastema disappears either by 
resorption or organization, and in this manner those patholo- 
gical collections of fat are formed which we find in a crystal- 
lized state. Whether fat can arise from the protein-compounds 
of an exudation, or from its other constituents, through a 
chemical metamorphosis, must be left at present undecided, as 
also must the question, whether, under certain conditions, a 
plasma consisting entirely or principally of fat can be sepa- 
rated from the blood ; in other words, whether the vessels 
can in a direct manner secrete fat. If this were the case, the 
process of the formation of fat would be much simplified, 
and more easily explained. There is no doubt that in many 
cases actual fat is secreted by peculiar morbidly formed 
secreting organs, similar to the sebaceous glands of the skin, 
the ceruminous glands, &c. which in the normal state secrete 
fat. This is, for instance, the case in many kinds of encysted 
tumours. 

Of the development of organized adipose tissue and fat- 
cells we have no certain knowledge ; indeed we do not know 
in what manner the normal formation of fatty tissue occurs. 
We may assume that in accordance with the general scheme 
of cellular formation, cells arise from a cytoblastema more 
or less similar to the blood-plasma, and that at a later period 
they become filled with fat, or that a cell-wall occurs as a 
secondary formation around the fat-globules, whereby, pro- 
bably, Ascherson's # theory of the formation of the haptogen 



* Miiller's Archiv. 1840, p. 44, &c. 



184 



PATHOLOGICAL EPIGENESES. 



membrane might find a practical application. I have never 
met with a case tending to give either of these explanations 
a greater degree of probability than the other. The law of 
analogous formation appears to be here so far in force, as, 
that pathological fat-cells are most frequently formed in those 
parts where in the normal condition an accumulation of fat 
exists, as we shall show when we speak of fatty tumours. 

The chemical elements of morbidly formed fat are the 
same as those of normal fat. Olein is the prevailing element 
in fluid, and margarin and cholesterin in solid fat. Sometimes 
butyrin is found in small quantities, recognizable by the 
peculiar odour of butyric acid, which it evolves on becoming 
rancid. Whether serolin, and the brain-fats, of which we 
know very little, occur in morbid formations is unknown. 

EPIGENESIS OF MUSCULAR TISSUE. 

The normal muscles are divided into those containing 
simple, non-striated fibres, and those consisting of compound 
striated, primitive fasciculi. The same division holds, also, 
with regard to morbidly formed, muscular substance. 

a. Muscles with compound, striated, primitive fasciculi. 
To these belong, in the normal body, the voluntary muscles 
of the trunk, head, and extremities, and the muscular 
walls of the heart.* There is no doubt that muscular sub- 
stance of this kind may be produced by a morbid process, 
but this can only be argued from consequences, and not directly 
observed. This epigenesis always consists in a hypertrophy 
of muscular substance existing in the normal condition, and 
is of most frequent occurrence in the heart. It appears that 
the volume of the muscles is increased without the single 
primitive fasciculi gaining in thickness ; hence, it must be 
concluded that their number is increased ; that is, that new 



* See Henle's Allgem. Anat. Plate iv. fig. 4. 



EPIGENES1S OF MUSCULAR TISSUE. 



185 



ones have arisen amongst those previously existing. This 
epigenesis is sometimes the consequence of a morbid process, 
as in hypertrophy of the heart ; sometimes it results from 
normaEy increased nutrition, as in the case where a muscle is 
strengthened by exercise, and consequently increases in the 
thickness and number of its primitive fasciculi. This is one 
of those cases where no decided boundary can be established 
between a normal and morbid process, and where our division 
becomes arbitrary. Here the epigenesis entirely follows the 
law of analogous formation ; the cytoblastema is, doubtless, 
the general nutrient fluid which continues to be secreted in 
increased quantity for a considerable time. The newly formed 
muscular fasciculi so closely resemble the previously existing 
normal formation, that they cannot be distinguished from 
each other. The morphology of this epigenesis is, there- 
fore, unknown; even the normal development of this form 
of muscular tissue is still in several respects unexplained. # 
The chemical relations of this epigenesis are, probably, very 
simple, for the chemical composition of muscular tissue is 
very similar to that of the protein-compounds. 

It is an interesting observation that after loss of substance in 
the muscles, new muscular substance is not formed even in cases 
where a large quantity of cytoblastema is at once secreted. 
The cicatrices seen in muscular tissue, are formed from areolar 
tissue, and the exudation from the surface of muscular 
tissue (as for instance of the heart), is converted, not into 
muscular substance, but into areolar tissue. These facts 
serve to confirm the general law that the cytoblastema more 
readily follows the law of analogous formation in proportion 
as it is given out in small quantities, and that very compli- 

* The different opinions respecting the development of this tissue 
may be seen in Henle's Allgem. Anat. p. 600 ; Bischoff's Entwick- 
lungsgeschichte, p. 446 ; and Valentin in Wagner's Handworterbuch 
der Physiologic vol. i. p. 715. 



186 



PATHOLOGICAL EPIGENESES. 



cated tissues are only formed when its quantity is very 
small. 

Those cases in which it has been asserted that the formation of mus- 
cular fibres from large masses of exudation, after inflammation, and 
similar morbid processes, has been observed, are doubtless, founded on 
error. In fact, the microscopic examination (the only decisive test), had 
been altogether neglected, as in the cases observed by Leo-Wolf.* Since 
the tendons of the muscles are, histologically, closely connected with 
areolar tissue, so also is there an intimate analogy between these 
pathological epigeneses in cases of regeneration. 

b. Simple, non-striated muscular fibres. — These are found 
normally in the muscular coat of the stomach and intestinal 
canal, in the excretory ducts of glands, in the ureters, the 
bladder, the uterus, and the fallopian tubes. They are often 
morbidly produced, causing thickening (hypertrophy) of the 
walls, either at circumscribed points, or over a considerable 
extent of surface; and as independent (fibroid) tumours. 
They likewise sometimes form a constituent of scirrhus. 

In the majority of cases this epigenesis is to be explained 
by the law of analogous formation, for a cytoblastema 
secreted in excess is, through the influence of the surrounding 
tissue, converted into a similar substance, as in cases of hyper- 
trophy. In this point of view it is interesting to observe 
that independent tumours of simple muscular fibres (fibroid) 
so far, at least, as my experience reaches, are only to be found 
where in the normal condition simple muscular fibres were 
previously existing ; as in the substance of the uterus, which 
is their most common seat, and in the muscular coat of the 
stomach and intestinal canal. 

Morphology and chemistry of their development. The 
pathological and normal development of simple muscular fibres 

* Tractatus anatomico-pathologicus sistens duas observationes raris- 
simas de formatione fibrarum muscularium in pericardio atque in pleura 
obviarum. Heidelb. et Lips. 1832, and Wutzer's Critique on it in 
Midler's Archiv. 1834. p. 451. 



EPIGENESIS OF MUSCULAR TISSUE. 



187 



are perfectly identical. In both cases nuclei are formed in 
an amorphous, and, usually, a fluid cytoblastema, which are 
at first roundish, but subsequently become elongated and 
pointed, somewhat in the form of an oat grain, and some- 
times arched. Around these there are formed elongated cells, 
which gradually join at the extremities, and at length become 
fibres.^ It is not, however, always that this mode of forma- 
tion can be clearly detected during development. In many 
cases we see only perfect nuclei, whilst the rest of the cyto- 
blastema between them seems to be converted into muscular 
fibre without any preceding formation of cells, as has been 
previously described in the development of areolar tissue. 
After complete development, the newly formed muscular 
fibres sometimes perfectly resemble the normal ones. Homo- 
geneous fibres, varying in diameter from the 800th to the 
400th of a line and parallel to each other, are formed with 
nuclei scattered lengthways over them. 

These nuclei are often distinctly visible, or, at any 
rate, always become so after the addition of acetic acid.f It 
is not always, however, that newly formed muscular fibres 
are so distinctly marked ; sometimes an aggregation of them 
will form a more or less amorphous mass, in which the 
tendency to fibrillation can be discerned, but the separate 
fibres cannot be clearly distinguished. On treating such a 
mass with acetic acid, the nuclei appear in consequence of 
the fibres vanishing. These are cases where the develop- 
ment of the muscular fibres is either incomplete, or where it 
remains stationary at a lower and imperfect stage. They 
occur most frequently in tumours, where, probably, in conse- 
quence of too large a quantity of cytoblastema, the law of 
analogous formation only acts imperfectly, and the epigenesis 
never attains its true type. Large masses of simple muscular 
fibres, such as frequently occur in morbid epigeneses (both in 

* Plate iv. fig. 4. 

t Plate iv. fig. 4. Plate vn. fig. 2. Plate viii. fig. 2 and 7. 



188 



PATHOLOGICAL EPIGENESES. 



cases of hypertrophy and in tumours), manifest on being cut 
through so close a similarity, in their physical appearance, 
with cartilaginous tissue, that they are frequently mistaken 
for it. Both are of milk-white colour, are semi-transparent, 
apparently homogeneous, and very solid, so as to craunch 
under the knife. Many morbid growths described both by 
ancient and modern authors as morbid cartilaginous tissue 
consisted, without doubt, of this newly formed muscular 
tissue. The difference between these tissues is perfectly 
obvious under the microscope. 

The chemical processes in this epigenesis appear to be 
extremely simple, for this muscular substance in its chemical 
properties, and probably, also, in its ultimate composition, 
differs but slightly from the coagulated protein-compounds. 



As in the tissues consisting normally of fibrin, there is 
immense variety in the volume of the fibres, rising gradually 
from the fibres of areolar tissue, which are the finest and most 
delicate, and have a diameter varying from the 2000th 
to the 1 200th of a line, to the thickest simple muscular 
fibres with a diameter varying from the 400th to the 300th 
of a line; so does the same variety exist in the morbid 
epigenesis of fibrous tissues. Newly formed fibres are 
frequently met with, which seem to hold an intermediate 
place between those of areolar and those of muscular tissue ; 
so that it is no easy matter to decide to which they belong. 
This is the case in some imperfectly developed formations, 

The above observations respecting the similarity of many 
of these formations to cartilaginous substance holds, also, 
with regard to many of those structures which consist of im- 
perfectly developed areolar tissue. 



ELASTIC TISSUE — GRANULAR PIGMENT. 



189 



EPIGENESIS OF ELASTIC TISSUE. 

Elastic tissue consists of fibrous elements, and closely 
approximates, histologically, to the fibres of areolar tissue, 
of fibrous tissue, and of simple muscular fibre. The chief 
distinction between it and them is a chemical one, namely, 
the insolubility of its fibres in acetic acid ; it is also morpho- 
logically distinguished from the above tissues by the fact that 
its fibres are thicker than those of areolar and fibrous tissues ; 
while, on the other hand, they are thinner than those of simple 
muscle. It is further characterized by a frequent dichotomic 
separation, and reticulated ramification of its fibres. The 
nucleated fibres of areolar tissue range themselves immediately 
with those of elastic tissue ; they may, indeed, be considered 
as a degeneration of these latter.^ 

Pathological epigeneses of this tissue doubtless sometimes 
occur; they are, however, but imperfectly known. It has 
been already observed, that in pathological epigeneses of 
areolar tissue, nucleated fibres sometimes occur amongst its 
ordinary elements. In scirrhus, I have myself frequently 
observed an epigenesis of genuine reticulated elastic tissue, as 
I shall show in the section on that morbid process. 

MELANOSIS. 

In the normal body, granular pigment holds a very 
subordinate place. It is found only in the eye, and in some 
individuals also in the hair, and in some parts of the skin.f 
It consists of fine granular molecules of brown or black 
colour, which are usually enclosed in cells of different forms 
and size. This is the case in the choroid coat of the eye and 

* Full information respecting the histological relations of this tissue 
may be found in Henle's Allgem. Anat. p. 399. Plate n. fig. 9, 10, 11. 
Valentin in Wagner's Handworterbuch der Physiologic vol. i. 
p. 667. 

f See Bruch's Untersuch. z. Kenntniss des kornigen Pigments. 1844. 
Henle's Allgem. Anat. p. 279. 



190 



PATHOLOGICAL EPIGENESES. 



in the coloured portion of skin, in which latter, however, 
in addition to pigment-granules, coloured nuclei are also pre- 
sent (Bruch, Krause # ). 

Pathological epigeneses of granular pigment are, however, 
very frequent. They appear as colorations of the skin, in the 
form of sun-burn, freckles, &c. ; in the internal organs they 
appear as melanosis in the lungs and bronchial glands, on the 
surfaces of the liver and of the spleen, on the inner and outer 
surfaces of the intestinal canal, and in tumours; also as 
frequently accompanying suppuration in the walls of foul 
abscesses. The morphological and chemical relations, as also 
the causes of these morbid formations of pigment are very 
various, and therefore a general consideration of them is diffi- 
cult. The following may be offered as a mere provisional 
sketch. 

In some cases the newly formed pigment is contained 
in true cells, analogous to the normal pigment-cells, which 
are surrounded with a distinct cell-wall, provided with a 
nucleus, and enclose very fine granular pigment-molecules 
of a brown or black colour. Such pigment- cells are found in 
melanotic tumours, in melanosis of the lungs and bronchial 
glands, and in the skin. They are more or less perfectly 
formed, but seldom or ever so regular as the pigment-cells of 
the choroid coat. They are usually of an indefinite roundish 
form.f I have never seen them united in a continuous layer, 
and so greatly compressed as to form polyhedra. In animals, 
(the horse and calf), where collections of pigment occur 
in the conjunctiva after inflammation, they ramify and 
sometimes assume a stellar form. Bruch appears to clas- 
sify the granular cells under this head ; but they contain 
molecules, which consisting of fat, only appear dark in 
refracted light, and are rather, on the contrary, white when 
seen by reflected light ; they therefore differ essentially from 

* Article, Haut in Wagner's Handworterbuch der Physiologie. 

t PI. i. %. 10 ; pi. ix. fig. 7. See also Bruch, op. cit. fig. 22, 23, 25. 



GRANULAR PIGMENT. 



191 



the dark-coloured molecules of true pigment which appear 
dark by reflected light. Sometimes the cells enclosing pig- 
ment-molecules are very indistinct, or appear to be entirely 
wanting ; indeed, in one and the same melanotic lung, aggre- 
gations of pigment are often found, some of which, when 
carefully sliced and examined under the microscope, are 
found to be enclosed in cells, whilst other aggregations in 
the same lung, on the most careful examination, present 
no enclosing cells, but the pigment-molecules appear to be 
deposited in a state of freedom in the parenchyma. 

I have never yet succeeded in directly observing the process 
of development of these pigment-cells. It may be supposed 
v that the cells are first produced, and that at a later period, the 
pigment-granules are by a metabolic power generated within 
them ; in favour of which view, we may quote those cases 
occurring in children with leucosis (albinos), in whom the 
pigment, originally absent, was afterwards developed. # We 
know also that in white rabbits, whose choroid membrane 
contains no pigment, it is only the pigment-granules and not 
the cells which are deficient. When, therefore, pigment is 
subsequently produced in albinos, it can only happen by the 
originally empty cells becoming afterwards filled with pigment- 
granules. According to this view, the above cases in which 
pigment-granules without surrounding cells occur, may be 
explained by the supposition that the cells were originally 
present ; but that after the deposition of the pigment in them, 
they became again resorbed, whilst the pigment itself remained. 
On the other hand, it may be supposed that the pigment- 
granules are first formed, and become afterwards surrounded 
by cells. I believe that I have myself once observed this 
occurrence in pigment-cells in expectoration, where aggrega- 
tions of black pigment-granules were surrounded by cells 
more or less clearly indicated, and it appeared as if secondary 
cells formed around the pigment-granules, just as in pus- 
corpuscles they form around the nucleus. But these observa- 

* A case of this nature is recorded in Midler's Archiv. 1836. Jahres- 
bericht, p. 192. 



192 



PATHOLOGICAL EPIGENESES. 



tions, which from their nature are most difficult, I do not 
regard as decisive. 

In a chemical point of view, the newly formed pigment 
closely resembles the normal pigment of the eye. The 
intensely black pigment, in melanotic lungs and bronchial 
glands, rendered as pure as possible by boiling in hydrochloric 
and diluted nitric acid, and then extracting with water, ether, 
and alcohol, appears from my repeated observations to be 
insoluble in sulphuric and hydrochloric acids, caustic am- 
monia, potash, and dilute nitric acid ; it dissolves only in concen- 
trated nitric acid, at the same time undergoing decomposition. 
It is not decolorized by chlorine, though Bruch asserts to the 
contrary. Dr. Schmidt analysed in our laboratory two por- 
tions taken from different bodies, which appeared to corres- 
pond in their chemical relations, and in their action towards 
the above re-agents; the first, taken from the intensely 
melanotic lung of a miner in Clausthal, gave, after the deduc- 
tion of 12.48£ of ashes, consisting of 10.6 silica (pulverized 
quartz), and 1.88 sulphate of lime: — 

Carbon . . . .72.95 

Hydrogen . . . .4.75 

Nitrogen . . . . 3.89 

Oxygen . . . .18.41 

100.00 

In the other experiment, on a lung, hepatized inferiorly, and 
whose bronchial glands were thoroughly melanotic, the deter- 
mination of the hydrogen could not be regarded as certain, 
in consequence of the smallness of the quantity subjected to 
analysis. It gave, after the deduction of 3.735& of ashes, con- 
sisting of silica (powdered quartz) : — 

Carbon .... 66.77 

Hydrogen .... 7.33? 

Nitrogen . . . .8.29 

Oxygen . . . .17.61 



100.00 



GRANULAR PIGMENT. 



193 



These two analyses show but little similarity. It would 
appear from them, that the newly formed pigment has a 
variable composition, which is probably connected with its 
development. They prove that the opinion that the pigment 
deposited is pure carbon, is, at least in these cases, altogether 
incorrect. Further, they show that this pigment is not the 
same as the normal pigment of the eye, in which Scherer # 
found 58£ carbon, and 13.75- nitrogen ; yet with all the respect 
that I entertain for Scherer's accuracy, it appears to me that 
the analysis should be repeated in consequence of the extreme 
difficulty of obtaining the pigment of the eye in a state of 
purity. 

Another kind of morbid pigment evidently arises from 
decomposed blood, and from a change in its colouring matter. 
Extravasated blood has sometimes, for instance in gangrene, 
and when it has a tendency to become decomposed, a brownish 
red, or even blackish colour, forming either soft clots or 
a granular mass.f This change appears not only to affect 
extravasated blood, but also that which is still contained in 
the vessels ; whilst some parts of vessels contain red blood, 
in other parts it becomes brownish or almost black. This 
change of the blood appears to be of a purely chemical 
nature, since it is observed in those cases where blood is 
extravasated into the stomach. It is then always changed in 
the above-mentioned way, for the acid of the gastric juice 
communicates to the colouring matter of the blood a brown 
or blackish tint, and at the same time coagulates the albumen 
of its serum in larger or smaller masses, so that ultimately the 
well-known "coffee-grounds" appearance is produced which 
occurs in all cases when blood has been effused into the 
stomach during the presence of the gastric juice. In fact, 
the same takes place, and may at any time be produced out of 
the body, when defibrinated blood is mixed with sulphuric or 



* Liebig u. Wohler's Annalen d. Chem. u. Pharm. vol. xl. p. 63. 
f See pi. ix. fig. 10. 

VOL. I. O 



194 



PATHOLOGICAL EPIGENESES. 



hydrochloric acid. What is done in these cases by acids, 
appears in others to be effected by gases, especially by sul- 
phuretted hydrogen and hydrosulphate of ammonia, as for 
instance in the course of the intestinal canal and in the adja- 
cent parts. In other parts also, changes of the blood into a 
mass similar to granular pigment are presented without our 
being able to perceive their chemical cause. An interesting 
case of this kind was recently communicated to me by my 
colleague Ruete. In a case of haemorrhoids with disease of 
the liver, there occurred without any apparent cause an effu- 
sion of blood under the conjunctiva of the eye, in the form of 
knots, by which the conjunctiva was projected forwards ; the 
effused blood was not resorbed, but gradually became of a 
black colour. The knots broke, and discharged a mass which 
was immediately brought to me for examination. It was 
intensely black, and with the naked eye could not be dis- 
tinguished from the black pigment of the choroid. Under the 
microscope it appeared as an undefined granular mass, with 
blackish brown portions. Neither pus-corpuscles nor granular 
cells were to be seen, nor any other trace of organization or 
cellular formation. The pigment was not changed either by 
nitric acid or by chlorine ; in its appearance it resembled 
blood-pigment changed by grangrene or by acids. 

The chemical composition of this abnormal pigment is not 
accurately known, but this much is certain, namely, that it 
is not changed by chlorine, or by acids ; and this is impor- 
tant as a means of distinguishing it from the following 
variety. 

A third kind of morbidly formed granular pigment is not 
an organized epigenesis, but a simple chemical precipitate, 
and consists of sulphuret of iron. It appears most frequently 
as a black or blackish blue pigment on the walls of unhealthy 
fetid abscesses ; but also as a slate-grey pigment on the sur- 
face of the liver, spleen, and intestinal canal. Under the 
microscope it appears as an aggregation of black granules of 
indefinite form — of molecules varying in size to the 100th of 



GRANULAR PIGMENT. 



195 



a line in diameter. These molecules are found sometimes 
singly, sometimes collected together in larger or smaller 
quantity between and among the elements of the tissue. In 
some few cases these granules are enclosed in cells.* This 
pigment has morphologically a great similarity to the first 
kind, but chemically the two are easily distinguished. It 
dissolves in acids, (acetic acid, nitric acid, &c.) whilst the first 
and second kinds are not affected by them. By supersatu- 
rating the acid solution with hydrosulphate of ammonia, 
it apparently returns to its original form, that is, it is 
again precipitated as sulphuret of iron. Concentrated 
acetic acid is the best test, for the other acids, by coagulating 
the albumen, conceal the minute black granules, just as if 
they dissolved them. 

The second and third kinds of morbid pigment-formation, 
sometimes occur together. On making a microscopic exami- 
nation, we then observe black granules of sulphuret of 
iron between the brown patches of altered and coagulated 
blood, f 

After the preceding observations, the conditions under 
which the two last kinds of morbid pigment occur may be 
easily explained. Acids change the blood-pigment in the 
stomach, and probably also in gangrene, since gangrenous 
fluids frequently have an acid reaction. Sulphuretted hydro- 
gen and hydrosulphate of ammonia, which frequently 
occur in the intestinal canal, effect changes in the blood- 
pigment, either in that canal, or (escaping from it by endos- 
mosis, or in cases of perforation through the newly formed 
opening,) upon the surfaces of the spleen and the liver. 
When, either simultaneously or independently, the iron of the 
blood is dissolved, and by means of hydrosulphate of ammonia 
is again precipitated, the deposition of sulphuret of iron takes 
place. But there is still much that is obscure in these 
processes. How happens it, for example, that the iron of the 

* See Plate ix. fig. 5. f See Plate ix. fig. 10. 

o 2 



196 



PATHOLOGICAL EPIGENESES. 



blood- pigment is so easily dissolved, when it is so difficult of 
extraction in normal hEematin, as Mulder # has shown to be 
the case. Probably the preceding decomposition of the 
blood plays an important part in this stage of the pro- 
cess. 

There can be no doubt but that the second kind of morbid 
pigment arises from the blood, and, further, from its colouring 
matter. Many writers, amongst whom Bruch is found, 
trace the origin of all kinds of granular pigment to the colour- 
ing matter of the blood. This is not impossible, but it can be 
nothing more than a supposition, For that both are coloured 
in the same way is no proof that the one arises from the 
other. We are acquainted with many examples in zoo- 
chemistry where colourless matters give rise to coloured pro- 
ducts ; and it is highly probable that in the formation of blood 
in the embryo, the hsematin arises from colourless matter. 
I have made a number of experiments by injecting blood 
into the abdominal cavity of animals, with and without the 
addition of sulphuretted hydrogen and hydrosulphate of 
ammonia, in order to convert it into granular pigment ; 
but all my attempts have been unsuccessful, nor was I 
more fortunate in producing even a trace of granular pigment 
by treating either fresh or putrid blood with various reagents. 
The generality of writers designate the pathological epigenesis 
of granular pigment by the general name of melanosis. 
But the three kinds above described must each have dis- 
tinct names. In the following pages I shall, therefore, 
designate the first kind as true melanosis, and the two last 
which depend upon chemical changes in the blood-pigment, 
and on the formation of sulphuret of iron, I shall name 
false or pseudo-melanoses. 

Gluge laughs at this distinction, and observes that the latter has 

* Marchand u. Erdmann's Journal fur praktische Chemie, 1844, 
No. xi. p. 186, &c. 



NERVOUS TISSUE. 197 

nothing false but its name.* Names have always formed a subject of 
contention, although they are of little importance. Happily facts can 
never be set aside by witticisms. Further details on melanosis will be 
given in our observations on melanotic tumours, and in the special 
department when we treat of the individual organs. 

EPIGENESIS OF NERVOUS TISSUE. 

The normal nervous substance consists of many elements 
histologically differing from each other. There are primitive 
nervous fibres which again are divided into cerebro-spinal, 
sympathetic (Volkmann and Bidder), and central ; further 
there are central and peripheral nervous corpuscles (gan- 
glionic vesicles), f 

The pathological epigenesis of nervous tissue is rare, and 
only a few of the above named elements have been observed 
to be morbidly produced. In the way of regeneration, it is 
confined so far as we at present know to the epigenesis of 
nervous fibre (cerebro-spinal and probably also sympathetic), 
since after division, and indeed after the excision of small 
portions of the primitive fibres, the separated extremities 
unite with one another by newly formed nervous tissue.^ 
The nervous fibres thus formed are very similar to the 
normal fibres, § only that according to Nasse, they are some- 
what smaller. The morphological process in this formation 
is little known, but indeed our knowledge of the normal 
process is very deficient. Doubtless the nervous fibres are 

* Atlas d. patholog. Anatomic Fasciculus. 3 Melanosis, pp. 7 
and 16. 

f Compare Henle's Allgem. Anatomie, p. 613, &c. ; Valentin in 
Wagner's Handworterbuch der Physiolog. vol. i. p. 686, &c. ; Volk- 
mann u. Bidder. Die Selbstandigkeit d. sympath. Nervensystems, Leip. 
1842. 

X Compare C. O. Steinrtick, de nervor regeneration, Berol. 1838; 
H. Nasse in Midler's Archiv. 1839, p. 405 ; Giinther u. Schon. Mul- 
ler's Archiv. 1840, p. 270. 

§ Plate v. fig. 10 and 11. 



198 



PATHOLOGICAL EPIGENESES. 



formed from a fluid cytoblastema — the general fluid of nutri- 
tion — in accordance with the law of analogous formation. 
But the formation is very slow, being not complete till five 
weeks, sometimes till three or more months after the injury. 
It is much slower than the formation of areolar tissue, blood- 
vessels, &c. Here as in all tissues of composite struc- 
ture and of high physiological dignity, the epigenesis is 
limited, that is, all the fibres that have been destroyed are 
not again formed, and the regeneration itself only proceeds 
under favourable conditions. Probably there are similar rela- 
tions in force here as in the striated muscles previously 
describedo 

Whether central nervous fibres and nervous corpuscles 
(ganglionic vesicles) can be again formed, is unknown. 

That encephaloid is not a morbid production of the nervous system, 
as was formally supposed, is shown in the section on that subject. 
Further details concerning hypertrophy of the nerves, nervous tumours 
(neuroma), regeneration of the substance of the brain, &c, will be given 
in the special department. 

EPIGENESIS OF CARTILAGINOUS AND OSSEOUS TISSUES. 

These two tissues, in relation to their pathological epige- 
neses, are so intimately connected, that we shall consider 
them together. 

Normal cartilage consists of two elements histologically 
distinct — the cartilage cells, and an intercellular substance. 
The latter differs in the different kinds of cartilage ; in true 
cartilage it is amorphous ; in fibrous cartilage it consists of 
fibrous tissue ; in other cartilages it exhibits an intermediate 
character, being sometimes amorphous and slightly channelled, 
at other times fibrous. # 

The morbid production of cartilaginous tissue is not un- 

* See Henle's Allgem. Anat. p. 791, and Valentin in Wagner's 
Handworterbuch der Physiologie, vol. i. p. 720. 



CARTILAGE AND BONE. 



199 



common, but still it is confined within narrow limits ; true 
cartilage is not regenerated, the loss of substance being sup- 
plied not by fresh cartilage, but by areolar tissue. This, 
arising from the perichondrium, in accordance with the law 
of analogous formation, depends in part upon the fact that 
true cartilage has no vessels, and that therefore after its 
destruction, the cytoblastema in its vicinity is chiefly supplied 
to the areolar tissue of the perichondrium, and follows its 
law of formation. This circumstance is, however, insufficient 
to explain the fact that in bone similar conditions occur, and 
yet it is commonly true osseous substance, and not areolar 
tissue which is formed as a consequence of regeneration. 
Fibrous cartilage, on the other hand, which does contain 
vessels, is regenerated, but not so much by the new forma- 
tion of cartilage-corpuscles as by the reproduction of fibrous 
tissue. The morbid production of true cartilaginous tissue 
is confined to cases of morbid formation of bone, (which are 
commonly, if not always preceded by the formation of carti- 
lage), and to the formation of a peculiar kind of tumour 
consisting of cartilaginous substance, and named enchon- 
droma. To this we shall return when we come to speak of 
tumours. It has been already mentioned that many morbid 
formations of an apparently cartilaginous nature, consist in 
reality of fibrous tissue, more or less perfect areolar tissue, or 
simple muscular fibre. Normal osseous tissue consists of dif- 
ferent histological elements — of radiating bone-corpuscles, and 
of an intermediate amorphous substance ; these in their union 
form tubes or laminae, which are differently arranged in dif- 
ferent bones, and indeed in different parts of the same bone, 
and in this manner are produced the osseous canals, the cortical 
substance, the spongy tissue, &c. in whose interstices other sub- 
stances foreign to the true osseous tissue are deposited, as mar- 
row, vessels, nerves, and areolar tissue. # The pathological epi- 



* See Henle's Allgem. Anat. p. 813, and Valentin, op. cit. p. 723. 



200 



PATHOLOGICAL EPIGENESES. 



genesis of osseous tissue is of frequent occurrence, as in the 
regeneration of destroyed or fractured bones, in hypertrophy 
of normal bone, which is sometimes local, forming a protu- 
berance on the external surface (exostosis) and is sometimes 
extended over the whole bone, or over several bones (hyper- 
ostosis). It sometimes occurs in parts, where in the normal 
condition no bone existed ; as in the dura mater, the sesa- 
moid bones, ossification of tendons, &c. ; in osseous tumours 
(osteoid), and in the ossification of cartilages which in the 
normal condition do not ossify, as for example, the larynx. 
In all these cases the newly formed osseous tissue more or less 
resembles normal bone ; it exhibits the osseous corpuscles 
with their intermediate substance, and bony lamellae, # whilst 
the arrangement of these elements offers, as in normal bone, 
the greatest diversity. 

The morphology and chemistry of development are here as 
in normal bone, still in many points obscure. What our 
experience has as yet taught us is as follows. In an amor- 
phous cytoblastema which is either liquid or solid, and yielded 
by the nutrient fluid or by fibrinous dropsy, cartilage-cells 
are first formed, and between them the amorphous intercel- 
lular substance of cartilage ; in short true cartilage. 
Simultaneously with this process, the original protein-com- 
pounds of the cytoblastema are converted into chondrin, 
which then changes into bone. In the first place the carti- 
lage-corpuscles are increased in size or number, so that they 
preponderate over the volume of amorphous intercellular 
substance, and adopting a peculiar arrangement, collect 
together in groups. From these groups of cells, cavities are 
formed, which by connecting with each other, produce the 
future medullary canals, and the cells of the spongy tissue. 
In them are formed marrow, vessels, &c. The intercellular 
substance separating the cavities, simultaneously undergoes a 
change ; it separates itself into layers — the future osseous 

* Plate ix. fig. 7—9, 



CARTILAGE AND BONE. 



201 



lamellae — in which the osseous corpuscles are formed. But 
since these ramifying canals extend over the original carti- 
lage-cells (indeed frequently the canals proceeding from the 
different bone-corpuscles appear to be in contact) they must 
enter the intercellular substance either by resorption or 
prolongation. Together with these morphological changes, 
some of a chemical nature take place. The osseous substance 
becomes impregnated with calcareous salts, whilst its organic 
basis either remains chondrin, as in most pathological forma- 
tions of bone, or is converted into common gelatin (colla). # 
Whether a formation of cartilage invariably precedes the 
pathological formation of bone has never been determined by 
direct observation ; the analogy of the normal formation, how- 
ever, renders this probable. In the regeneration of bone the 
pre-formation of cartilage is undoubted. Very many of what 
are termed pathological formations of bone or ossifications 
are nothing more than concretions, of which we shall speak 
hereafter. 



In the foregoing pages we have considered the most im- 
portant of the elementary tissues which admit of pathological 
re-formation : there are some others whose epigenesis can 
only occur under definite and very limited conditions — as hair, 
nails, teeth, and glands, which will be considered in their 
proper places. 

* For full particulars respecting the morbid as well as the normal 
formation of bone, the reader may consult, in addition to the works of 
Henle and Valentin already quoted : BischofFs Entwicklungsgeschichte, 
p. 432 ; Miescher de inflammatione ossium eorumque anatomia generali, 
Berol. 1836 ; Mayer in Muller's Archiv. 1841, p. 210; Fleischmann in 
ditto, 1843, p. 202; Bidder in ditto, 1843, p. 372. 



202 



PATHOLOGICAL EPIGENESES. 



TUMOURS. 

When the pathological epigeneses of the elementary tissues, 
treated of in the preceding pages, do not serve to unite 
portions of the body severed by wounds, or to restore 
loss of substance ; when further they do not, as in hyper- 
trophy, increase the mass of an organ by the addition of new 
substance similar to, and not to be distinguished from the 
original ; but when, on the contrary, the newly formed mass is 
more or less distinct from the surrounding parts, and when 
the scalpel of the anatomist can separate it from them and 
isolate it, such an epigenesis is commonly named a tumour. 
The idea attached to the word tumour is, however, very inde- 
finite, and there is no distinct line drawn between tumours and 
regeneration of lost parts and hypertrophies. Again the 
tumours occurring in individual cases show an endless variety. 
There occur as elements in their composition, not only the 
several tissues of whose epigeneses we have already spoken, 
but also many others which find no place in the normal 
body ; and these several elements appear in certain cases under 
infinitely varied combinations. Hence a classification of 
tumours is extremely difficult, and all attempts to arrange 
them (as we do animals and plants) into genera and species 
must necessarily fail ; this does not, however, prevent us from 
ranging them in some sort into groups, in order that we may 
the more easily proceed in our consideration of them ; but we 
must always bear in mind that there is no definite division 
between one and another of them, and that through the various 
combinations of their composite elements, they offer an infinite 
variety of form. 

In a histological point of view, tumours may be arranged in 
two great divisions. To the first belong those whose elements 
may be considered histologically to agree with those of the 
normal body, and which further being once formed, discharge 



TUMOURS. 



203 



the duties of the normal constituents of the body, take a part 
in the general metamorphosis of tissue, and are nourished and 
increased like other parts. These are homologous, non- 
malignant tumours. 

In the second division, we must place those whose elements 
in a histological point of view differ more or less from those 
of the normal body, and which (as in the process of suppura- 
tion) from their nature give way, soften, and destroy the 
organic parts which surround them or which they enclose — 
heterologous, malignant tumours. 

But even this division cannot in all cases be strictly adhered 
to, for if there are not peculiar intermediate structures, 
there are at any rate combinations of tumours, in part belong- 
ing to the one, and in part to the other division ; as for 
instance, scirrhus, in which there is invariably a combination 
of homologous with heterologous elements. * 

Although there are many tumours which can be most distinctly sepa- 
rated from all others, as for instance, many encysted, adipose, and 
fibrous tumours, and some forms of encephaloid and colloid, yet in many, 
indeed, in the majority of cases this is not possible ; hence such divisions 
as have been attempted by Plenck in accordance with the suggestion of 
Baglivi, into genera and species, necessarily fail, at least for the higher 
problems of science. Pathological anatomy must attempt to arrange 
them according to their histological elements, but since these in indi- 



* The most important literature on the general relations of tumours, 
and on their classification, is embraced in the following works : J. J. 
Plenck, novum systema tumorum, Vienna?, 1767; Dictionn. des 
sciences medic, vol. lvi. p. 107 ; J. Abernethy, an attempt to form a 
classification of tumours. Surgical observations, London, 1804; Laen- 
nec in the Dictionn. des sciences medic, vol. n. p. 54 ; Meyen, 
Unters. iiber die Natur parasitischer Geschwulste, Berlin, 1828 ; 
Joh. Muller iiber den feineren Bau und d. Formen der krankhaften 
Geschwulste, Berlin, 1838, or Dr. West's English translation, Lon- 
don, 1840; F. Th. Frerichs de polyporum structura penitiore, Leerse, 
1843 ; and the various treatises on pathological anatomy by Voigtel, 
Meckel, Andral, and Lobstein. 



204 



PATHOLOGICAL EPIGENESES. 



vidual tumours are combined in the most varied manner, and to a cer- 
tain degree appear vicarious in relation to one another, it is impossible 
to arrange them as species, and we can only classify them according to 
their formations. 

The above leading division of tumours, into homologous or non- 
malignant, and heterologous or malignant, whilst it avoids the danger 
of misleading, appears to me to be conformable to nature, and practi- 
cally useful. Lobstein has preceded me in adopting it. Objections 
have recently been raised against it on the ground that heterologous 
epigeneses depend on the same laws (cellular formation, &c.) as the 
normal, and that in some of them, homologous formations likewise 
enter, as in scirrhus. This objection seems to refer only to epigeneses 
in the mass, and not to the individual elements. The more accurately we 
become acquainted with these, the more sure shall we be that in the 
second division of these tumours, elements actually occur which are 
foreign to the normal organism, and that these foreign elements are the 
true ground of their malignity. The fact must, however, be borne in 
mind that these heterologous elements cannot at every degree of their 
development be with certainty distinguished from the homologous, and 
consequently many cases arise in which after the most careful histological 
examination, it is impossible to discover whether a tumour is of the 
non-malignant or the malignant class. Finally it has not always been 
clear wherein consisted the non-malignant or the malignant character of 
a tumour. It has been generally agreed that the non-malignity of a 
tumour consisted in the circumstance that it would not be reproduced 
after extirpation ; those which after extirpation were again pro- 
duced being held as malignant. This view I regard as incorrect; 
tumours which are manifestly non- malignant, as for instance encysted 
tumours, may again reappear though the same originating force which first 
produced their development, whilst tumours notoriously malignant may 
never return after their extirpation, or may even vanish of themselves 
provided that the disposition to their formation no longer exists, as has 
been undoubtedly shown in relation to pulmonary tubercle. The 
malignity which forms the grand principle of division between these two 
classes of tumours is connected with the very nature of the tumour 
itself, and depends upon its histological elements. Indeed the clear 
distinction between malignant tumours and unhealthy suppuration, &c, 
disappears ; but this separation is only artificial and not based on nature. 
The above provisional remarks are sufficient to give the reader an idea 
of the principles I adopt in the classification of tumours. 



NON-MALIGNANT TUMOURS. 



205 



OF NON-MALIGNANT TUMOURS ANALOGOUS TO THE NORMAL 
ELEMENTS OF THE BODY. 

To this class belong those tumours whose elements agree 
with the newly formed tissues, occurring in cases of regene- 
ration and hypertrophy. The tissues which occur in them 
are areolar, fibrous, and simple muscular tissue, adipose 
tissue, vessels, granular pigment, cartilaginous and osseous 
tissues, and in a few cases also hair, teeth, &c. Sometimes 
they consist principally of a single tissue, but more frequently 
of several in conjunction, and in the utmost possible variety of 
combinations. Some of them are intimately connected with 
the surrounding normal parts of the body, and arising from 
the same elements, form as it were a sort of hypertrophy. 
Others are quite distinct from the surrounding parts, some- 
times even so far as to be surrounded by a membrane which 
either consists of the normal elements of the surrounding 
parts (chiefly areolar tissue) compressed by the tumour, or 
else is itself a pathological epigenesis. This membrane is 
most clearly seen in those tumours which are termed en- 
cysted. 

As in their histological composition, so also in their modes 
of origin and development, there is an entire similarity 
between these tumours and cases of regeneration and hyper- 
trophy. They follow in all respects the general law which 
has been previously laid down for the pathological formation 
of the elementary tissues. They further resemble cases of 
regeneration and hypertrophy in their physiological functions 
and in their further progress. Like them they exhibit various 
properties in their several stages of development ; like them 
they are nourished and increased, and form persistent consti- 
tuents of the body, often enduring many years before death 
supervenes, usually increasing and very rarely becoming 
smaller. It is upon these circumstances that their non- 



206 



PATHOLOGICAL EPIGENESES. 



malignity depends. In those cases where they become hurt- 
ful to the organism, and even soften like malignant tumours, 
that depends not on their own nature, but on fortuitous 
external circumstances. They may, for instance, become inju- 
rious from their size, and from their pressure on surrounding 
parts ; they may ^proceed to inflammation and suppuration 
when they are situated on the outer surface of the body, 
where from their prominent position they are particularly 
exposed to mechanical injuries, as blows, the pressure of 
dress, &c. They may also be combined with malignant 
growths, especially with tubercles and encephaloid, which may 
be deposited in them exactly as in normal parts of the body. 
In scirrhus as we shall presently see, such a union of non- 
malignant and malignant elements occurs. 

Pathological anatomy has as yet done but little in eluci- 
dating the causes of their formation. In their commence- 
ment they are usually small, and they undoubtedly depend on 
the formation of a cytoblastema which becomes organized and 
gradually forms a tumour. Sometimes a mechanical injury, 
as a thrust or a blow, appears to produce a cytoblastema of 
this kind, which is then doubtless extravasated blood and 
coagulated (rarely fluid) fibrin. 

A cytoblastema of this kind appears, however, usually to 
be produced by internal causes, such as locally increased 
secretion with hyperemia of the capillary vessels, and only 
seldom to arise from true inflammation. The organization of 
this blastema usually follows the law of analogous formation ; 
thus in adipose regions of the body, tumours appear which 
consist principally of fatty tissue ; in parts consisting chiefly 
of areolar and fibrous tissue, we have fibrous tumours ; and 
in muscular coats, tumours of simple muscular fibre ; under 
the skin we often find encysted tumours whose membranes 
have a histological composition analogous to that of the 
cutis, with glands, hair-bulbs, and epithelium. But all the 
relations connected with the formation of non-malignant 
tumours, do not admit of this mode of explanation. Many 



VASCULAR TUMOURS. 



207 



of them are quite inexplicable, as, for instance, the formation 
of hair, teeth, and bone in encysted tumours of the ovaries. 
When a tumour is once formed, it takes its share with the 
rest of the body in the general metamorphosis of tissue, and 
the part is often an active one, since most of these tumours 
possess considerable vascularity, and there can be no doubt 
that they usually owe their increase to the irritation which 
they set up in the surrounding parts, their vessels becoming 
hyperaemic, and therefore yielding more than the ordinary 
quantity of cytoblastema. 

Most of the above tumours may be arranged under one of 
the following groups. 

FIRST GROUP. 

TUMOURS CONSISTING PRINCIPALLY OF VESSELS. 

Vascular Tumours. 

Non-malignant tumours which consist principally of blood- 
vessels with small quantities of intermediate areolar tissue 
have received the name Telangiectases. More or less syno- 
nymous with these are those denominated : Aneurysma per 
anastomosin, Tumeur erectile, Tumor splenoides, Hcema- 
toma, Hcematoncus, N&vus vasculosus, &c. 

These tumours are of red or bluish-red colour, of various 
forms and sizes, more or less firm, and more or less capable of 
temporary erection, like the normal erectile tissues. They 
generally appear on the external skin, or in the subjacent cellu- 
lar tissue upon various parts of the body ; as on the head, 
scalp, cheeks, eyelids and lips, also on the trunk, the 
arms and the lower extremities. They are usually congenital 
but afterwards increase in size; in some cases, however, 
they are first produced after birth ; and occur both in 
children and in adults, often without any perceptible cause, 
but sometimes after a mechanical injury, as for instance, a 
contusion. 

On examining one of these tumours in the dead body, 



208 



PATHOLOGICAL EPIGENESES. 



or after extirpation, it usually appears white and blood- 
less, because the fluid contents very rapidly escape ; but 
on placing a small portion under the microscope imme- 
diately after extirpation, the smaller vessels, at the least, 
will be seen partially rilled with blood. A section after 
being thoroughly washed, is observed either by the naked 
eye, or by a lens, to have a cribriform appearance, the orifices 
corresponding with the sections of the divided vessels. # On 
examining carefully prepared sections under the microscope, 
the walls of the vessels may be discerned, and between them 
perfect or partially developed areolar tissue, caudate cells and 
nuclei. The vessels have usually a tolerably large diameter, 
being very distended capillaries, small arteries, and small 
veins; when arteries predominate, the tumours during life 
exhibit pulsation; and when veins, they present a bluish 
colour.f 

Their development depends either on dilatation of the 
normal capillaries, the ends of arteries and the commence- 
ment of veins, at first only temporary and produced by the 
same causes which give rise to local hyperemia and subse- 
quently becoming permanent ; or else on an epigenesis of 
vessels in the manner previously described. When Telan- 
giectases form true prominent tumours, in addition to the 
formation of vessels, there is always an epigenesis of areolar 
and fibrous tissue. 

True Telangiectases are never encysted, but are intimately 
connected with the surrounding parts, and are altogether 
non-malignant. When they are situated in the subcutaneous 
cellular tissue, they may sometimes become dangerous, by 
the gradual tension and attenuation of the skin, by sponta- 
neous rupture of their vessels, bleeding, inflammation, sup- 
puration, &c. 

* J. Muller, fiber den fein. Bail und die Formen der krank. Ge- 
schwulste, Plate in. fig. 15 and 16. 
f J. Midler, op. cit. Plate in. fig. 17. 



FATTY TUMOURS. 



209 



Most kinds of tumours, non-malignant as well as 
malignant, are in some degree furnished with vessels. These 
tumours when the vessels predominate, may be regarded 
as a combination of some other form with the vascular. 
Such combinations frequently occur at a certain stage of 
malignant tumours, namely when they soften, break up and 
form on their surface luxuriant and very vascular spongy 
granulations. Hence arises a peculiar form of malignant 
epigenesis, termed Fungus hamatodes, of which we shall 
speak hereafter, and which must not be confounded with true 
Telangiectasis. 

Common as vessels are in other forms of tumours, yet except in the 
case of common vascular tumour, they play only a subordinate part, the 
characteristic properties being dependant on other tissues. Hence that 
appears an unsuitable arrangement of Abernethy,* in which he places 
tumours containing vessels in a class or species by themselves ; for his 
" common vascular or organized sarcoma," embraces within its range many 
tumours differing exceedingly from one another in their essential proper- 
ties. In our observations upon the different tumours, we shall continually 
return to the consideration of the relation in which vessels stand to the 
remaining elements of their composition. With regard to the varieties of 
vascular tumours, we shall say more in the special part in which we 
treat of tumours in the different organs. 

SECOND GROUP. 

TUMOURS CONSISTING PRINCIPALLY OF ADIPOSE TISSUE. 

Fatty Tumours. 

In many tumours fatty tissue is the prevailing element ; 
indeed some tumours consist of it alone. To such we apply 
the term Lipoma. In appearance they resemble normal fatty 
tissue : when recent, they present to examination a soft mass 
of yellowish colour, with a fatty feeling, which on being dried 
or heated gives out fluid fat, forming greasy spots upon 
paper. 



* Abernethy's Surgical Observations, p. 19. 
VOL. I. P 



210 



PATHOLOGICAL EPIGENESES. 



Under the microscope they appear to be composed of 
an aggregation of fat-cells, which perfectly accord with those 
of the normal fatty tissue. These fat-cells vary from the 
1 2th to the 2 1 st of a line in diameter, and are round or else 
laterally compressed into a polyhedric form. They consist of 
an amorphous cell-wall which sometimes, but not often, 
encloses an undoubted nucleus, and of fluid fat contained in 
the interior. The fat may be thoroughly taken up by boiling 
alcohol or ether. It is chemically identical with the ordinary 
human fat, and consists of a mixture of olein and margarin. 
Sometimes the latter is present in so large a quantity, that as 
the body cools after death, or the tumour after extirpation, 
it forms acicular crystals, which appear either singly or in 
stellar groups in the interior of the fat-cells. # The cell-wall 
probably consists of a protein-compound. 

When a fresh tumour of this kind is submitted to pressure 
under the microscope, some of the fat cells burst, and the fat 
escapes from them in the form of oil-globules. These appear, 
therefore, to be an artificial product. 

In a true lipoma, I have never seen free fat-globules. 
In the normal fatty tissue, there are vessels and fibres 
of areolar tissue, in greater or less abundance, between 
the true fat-cells; and the same is the case in fatty 
tumours. Sometimes the vessels, and more especially, 
the areolar tissue are very sparingly found. In other cases, 
on the contrary, the areolar tissue abounds, forming tough 
fibrous partitions between the parcels of fatty cells.f The 
tumour is firm and solid, assuming more or less the physical 
qualities of lard, in proportion as the areolar tissue abounds. 
It then receives the name of lardaceous tumour (Steatoma or 
Tumeur lardacee). Fatty tumours are thus histologically 
combined with the next group, namely, fibrous tumours. 



* Plate x. fig. 3. 



f Plate vii. fig. 1. 



FATTY TUMOURS. 



211 



Between the true fatty and the true fibrous tumour, there 
seems an almost infinite number of transition forms. 

Fatty tumours are more or less clearly distinct from the 
surrounding parts. Sometimes they are most intimately 
connected with the normal fatty tissue, and these must be 
regarded as cases of local hypertrophy. In other cases they are 
more or less clearly surrounded by a cyst. This cyst usually 
consists of a kind of sheath of areolar tissue, which is, how- 
ever, generally very imperfect and of different thickness at 
different parts ; it is connected with the inner layer of areolar 
tissue which penetrates the tumour, and thus serves rather to 
connect the tumour with the surrounding parts than to 
separate it from them. In some cases, however, this sheath 
is more clearly formed, becoming, indeed, a perfect cyst, 
entirely dividing the tumour from the parts in its vicinity. 
These cases form the transition between the true fatty tumours 
and the genuine encysted tumours. Of this transition we 
shall speak hereafter in our observations on encysted tumours. 
The vessels in fatty tumours are usually few, and for the most 
part small, as is also the case in normal fatty tissue. Fatty 
tumours are sometimes congenital, but they likewise arise at 
every age and in various parts of the body ; commonly in the 
subcutaneous fatty tissue of the shoulders and the buttocks, 
but also on the face, the extremities, and the internal parts of 
the body, especially the omentum. They appear to be more 
frequent in women than in men (v. Walther, Chelius). 
Their growth is more or less rapid, and they often attain a 
very considerable size. Those of the size of a cherry have 
been observed increasing to the size of an apple, and indeed 
to that of the head, and have been known on extirpation to 
weigh as much as twelve, twenty-one, or twenty-five pounds, 
and even more. They sometimes appear singly, sometimes 
several occur simultaneously on different parts of the body of 
the same individual. Fatty tumours are in themselves 
always non-malignant, yet they are apt frequently to reappear 

p 2 



212 PATHOLOGICAL EPIGENESEs. 

after extirpation.* They may be injurious to the organism in 
many ways and may even prove dangerous. By pressing 
upon nerves they sometimes cause frightful sufferings (Weid- 
mann, v. Klein). These injurious effects increase with their 
size. Those occurring on the external parts disfigure the 
appearance and distend the skin, causing dilatation of the 
superficial veins in consequence of their having to take on the 
duties of the deeper vessels, which are compressed by the 
tumour. They become incommodious from their weight. The 
distended skin and compressed adjacent parts inflame, suppu- 
rate, and ulcerate, and these actions proceeding with increasing 
virulence, the patient ultimately sinks from hectic fever and 
exhaustion. Many steatomatous tumours are combined with 
malignant growths and become scirrhus ; at least so it is 
believed, though as histological proof is wanting, it is not 
impossible that sometimes their destruction by suppuration 
rnav have been confounded with the formation of carcinoma. 

The causes giving rise to fatty tumours are still very 
obscure. It may be that the first foundation of these tumours 
is in a local increased deposition of cytoblastema converted 
into fatty tissue. In this change the law of analogous forma- 
tion takes an active part, for these tumours principally arise 
in those regions which in the normal condition abound in fat. 
External causes frequently give rise to an increased secretion 
of blastema ; a blow or thrust may cause it ; but, as often, we 
can point to no external cause. This need not surprise us, 
when we consider how frequently, without any appreciable 
external cause or even symptom, extravasations of blood and 
collections of fibrinous fluid, coagulated fibrin, &c, present 
themselves in the interior of the body, which under favourable 
circumstances might doubtless be converted into fatty 
tumours. As in the normal formation of fat, there is much 
that is still obscure, so in the formation of fatty tumours, 

* See the description of Plate vn. fig. 1. 



FATTY TUMOURS. 



213 



we are still more in the dark in relation to the mode in 
which their nutrition is conducted. It is further probable, 
that sometimes as Abernethy # has conjectured, an imper- 
fectly formed tumour of another kind, as for instance a 
fibrous tumour, through a change in the mode of its nutrition, 
may take up fat and thus become converted into a fatty or 
lardaceous tumour. When a tumour has once formed, it 
increases in accordance with the law of analogous formation, 
which in this case is identical with the laws regulating 
normal nutrition. As the histological examination of tumours 
is only of very recent origin, it is difficult and often impos- 
sible to determine the nature of the tumours described by the 
earlier observers. 

From the absence of microscopic examination and description, it is 
impossible to identify the tumours described by the older writers. f Of the 
tumours belonging, according to the old terminology to this group, there 
are : lipoma, some cases of lupia (many belonging to encysted tumours), 
some cases of steatoma (which, as has been already remarked, forms the 
transition to fibrous tumours), and a small portion of the cases of sar- 
coma (Abernethy's adipose sarcoma ; most, however, belonging to the 
group of fibrous tumours). MullerJ distinguishes the following varieties 
of lipoma: 1. Lipoma simplex — the true fatty tumour. 2. Lipoma 
mixtum, with penetrating membranous layers — the combination with 
the fibrous tumour, forming steatoma; and 3. Lipoma arborescens — 

* Surgical observations, p. 9. 

f The following works constitute the most important literature of the 
subject: Abernethy's Surgical Observations, 1804, p. 26 ; Ph. Fr. v. 
Walther, iiber die angebornen Fetthautgeschwulste, Landshut, 1814,. 
m. 2 Tab. ; J. P. Weidmann, Annotatio de steatomatibus, Moguntiaci, 
1817, acc. 5 Tab.; J. Fr. Meckel, Handb. der Pathol. Anatomie, 
vol. ii. Part. ii. 1818, p. 119, &c. ; v. Klein, uber Speckgeschwulste, 
v. Graefe und v. Walther's Journal, vol. i. p. 109 ; Chelius, Handb. d. 
Chirurgie unter Fettgeschwulst und Steatoma; J. M tiller, iiber den 
feineren Bau und die Formen der krankhaften Geschwiilste, 1838, 
p. 49 ; G. Gluge, Abhandlungen zur Physiologie u. Pathologie, 1839, 
p. 130, 1841, p. 185 ; D. Heyfelder de lipomate et steatomate, 1842; 
numerous references to, and quotations from the older authors, are 
given in these works. 

+ Op. cit. p. 50, or West's translation, pp. 153 — 4. 



214 



PATHOLOGICAL EPIGENESES. 



ramifying productions consisting of fatty tissue, and occurring in the 
joints, especially at the knee joint. Growths of this sort are covered by 
a prolongation of the synovial membrane, and hang loosely in the cavity 
of the joint, forming arborescent tufts somewhat swollen at their extre- 
mities. V. Walther* distinguishes as a peculiar variety, the Ncevus 
lipomatodes, a lipoma appearing at birth in the subcutaneous fatty 
tissue, and connected with a change in the cutis. Glugef describes 
under the name of Lipoma colloides, a particular kind of fatty tumour, 
upon which I can at present offer no opinion. The chemical relations of 
fatty tumours may be easily deduced from the foregoing observa- 
tions. 

After the preceding observations, it will not be expected 
that we should attempt a division of fatty tumours into pre- 
cise species and sub-species ; but if it be desired to form a 
tolerable idea of the several possible and actual forms which 
they take, or changes which they experience, the following 
arrangement may be serviceable. The true fatty tumour 
may pass : 

1. Into general infiltration of fat (polysarcia, obesitas), by 
local hypertrophy of the adipose tissue. 

2. Into fibrous tumour, by the accession of areolar tissue. 

3. Into encysted tumour, by the production of a decided 
cyst. 

Probably there are occasional transitions into other kinds of 
tumours, even into those of a malignant nature. 

The transition into the vascular tumour is doubtful, since 
vessels in fatty tumours always play a very subordinate 
part. 

In reference to their diagnosis it must be mentioned that 
many forms of malignant tumour — as encephaloid — have in 
their physical properties, the greatest similarity to fatty 
tumours, and can only be distinguished from them by micros- 
copic examination. For particulars on this subject we must 
refer to the section on malignant tumours. 

* Op. cit. p. 22. 

t Op. cit. 1838, p. 131, &c; 1841, p. 185, &c. 



FIBROUS TUMOURS. 215 



THIRD GROUP. 

TUMOURS CONSISTING PRINCIPALLY OF FIBROUS TISSUE. 

Fibrous Tumours. 

Tumours of which the prevailing element is fibrous tissue 
are very frequent, but they appear under so many varieties of 
form, not only in their physical properties, but also in their 
histological arrangement, that it is difficult to assign to them 
any general characteristic. Their varieties are not merely 
dependant on their being combined with other forms of 
tumour, but also on the different stages of development of 
the tissue. 

We shall therefore in the first place attempt to give certain 
elementary types of these tumours. The forms which are 
most definite and easy of determination, are those where the 
fibrous tissue appears perfectly formed. This tissue as seen 
under the microscope consists of fibres, which can be more 
or less easily separated, and are sometimes very fine, some- 
times tolerably thick, their diameter varying between the 
2000th and the 400th of a line. The fibres of the same 
tumour, are, however, pretty generally of nearly the same 
thickness. Histologically these fibres resemble either those 
of normal areolar tissue, in which case they are fine and 
measure from the 2000th to the 1 200th of a line ; or they 
resemble those of the normal fibrous tissue, as of fibrous 
membranes and tendons, in which case they are somewhat 
thicker, and measure from the 1200th to the 900th of a line; 
or lastly they resemble normal simple muscular fibre, in 
which case they are broader, and have a diameter varying 
from the 900th to the 400th of a line. All these fibres are 
rendered transparent by acetic acid, becoming gradually pale 
till they disappear : occasionally, however, a few larger ones 
(varying from the 1000th to the 500th of a line) remain 
unchanged in acetic acid ; these divide in an irregular manner 



216 



PATHOLOGICAL EPIGENESES. 



and penetrate the tumour. These fibres insoluble in acetic 
acid, correspond with the nucleated fibres of areolar tissue. 
On the other hand, after the application of acetic acid, there 
appear more or less numerous groups of oval, or sometimes 
pointed, oat-shaped nuclei, presenting occasionally a curved 
appearance, similar to those which appear in the normal for- 
mation of fibrous tissue. In none but mature and perfectly 
formed tumours are these nuclei ever absent. We may also 
frequently remark between the perfect fibres, fusiform 
nucleated cells, apparently arrested in their development. 
They are found when a fresh section of the tumour has been 
pared off with a blunt knife, and is placed in water under the 
microscope.* In future for the sake of simplicity, we shall 
subdivide this class into tumours of areolar tissue, tumours 
of fibrous tissue, and tumours of simple muscular fibre. It 
is frequently, however, impossible to follow this arrangement, 
for fibrous tissue when morbidly reproduced, shows various 
degrees of inclination to one or to another of these varieties, 
so that after the most careful examination, it is not always 
possible to determine whether the fibrous tissue of a 
tumour most approximates to areolar tissue, normal fibrous 
tissue, or simple muscular tissue. But the division, if not 
pushed too far, will be found to be grounded on their true 
nature, and practically useful in relation to the genesis of the 
tumour. 

Notwithstanding the similarity of their elements, the 
tumours of this group present veiy material differences in the 
histological arrangement of their fibres, and together with 
this they present also great variations in their physical proper- 
ties. It is only in rare cases that the fibres are loosely con- 
nected with each other, easily isolated into either single fibres, 
or connected fasciculi with an undulating appearance, as in 
normal areolar tissue. In these cases, the tumour is soft, 
flexible, more or less elastic and coriaceous, resembling in 



* See Plate vn. figs. 2, 3, and 4, and their explanation. 



FIBROUS TUMOURS. 



217 



its physical properties the tissue of the cutis (Desmoid 
tumour). More frequently the fibres are closely compressed, 
separated with difficulty, and united into a solid mass. The 
tumour is then solid, firm, and very elastic, cannot be drawn 
asunder, and craunches under the knife ; and the section pre- 
sents a map-like appearance. This form is called Sarcoma, 
or Fibroid. When the union and fusion of the fibres reaches 
a yet higher degree, the tumour becomes very firm, almost 
homogenous, and of a milk white colour ; it is more easily cut 
into thin layers than separated into fibres, and has in its 
physical properties the greatest similarity to cartilaginous 
tissue, without, however, resembling it in a histological point 
of view (Chondr old tumour). This form presents the transi- 
tion to the second class of fibrous tumours, where instead of 
fibres, a more amorphous mass is presented. 

Other differences in fibrous tumours are dependant on the 
manner in which the fibres are arranged. Sometimes they run 
irregularly in every direction, as in the normal cutis ; this is 
usually the case in those fibrous tumours which are developed 
upon the external skin, or upon mucous membranes, (warts, 
condyloma, fibrous polypi, &c.) In other cases the fibres are 
arranged in a regular manner, in concentric or twisted circles, 
and sections of such tumours sometimes present very beautiful 
designs, visible to the naked eye ; this is the case with the so 
termed fibroid of the uterus. # 

Not less various are the ways in which fibrous tumours are 
connected with their surrounding parts, and also the 
forms in which they occur. Many of them are most inti- 
mately connected with, and as it were, fused into the sur- 
rounding parts, and form the transition to the hypertrophy 
of such organs as in the normal condition consist of fibrous 
tissue. Thus in the stomach, the intestinal canal, and the 

* See Gluge's Atlas der pathol. Anatomie, Part iv. Tab. 4, fig. 14, 
15; and Hope's Principles and Illustrations of Morbid Anatomy, 
fig. 215. 



218 



PATHOLOGICAL EPIGENESES. 



uterus, we frequently meet with every stage of transition 
from isolated fibrous tumour to local hypertrophy: and 
condylomata, warts, and fibrous polypi form transitions from 
the isolated fibrous tumour to local hypertrophy of the 
cutis and mucous membrane. In all these cases it must of 
course follow that just in proportion as the tumour is less 
isolated, and more connected with the surrounding parts, in 
such proportion its form must be undefined. Other fibrous 
tumours are definite circumscribed and less closely connected 
with the surrounding parts, usually being separated from 
them by a kind of cyst of areolar tissue, which, however, as 
we have already mentioned in our observations on fatty 
tumours, is more closely united to the surrounding parts than 
to the tumour. In these cases the external form of the 
tumour is more defined ; it is commonly irregularly round, 
but occasionally presents an interlaced or ragged appearance. 
Sometimes the fibrous tumours are so perfectly isolated, that 
they show scarcely any connection with the surrounding 
parts, but lie free from them as it were in a sheath, and 
on cutting the surrounding capsule fall out. This is occa- 
sionally noticed in fibrous tumours of the uterus, which are 
sometimes quite detached (like a knot in a board) in the 
parenchyma of that organ or in its cavity, so that, in some 
cases even during life, they can be removed without sup- 
puration or other process of destruction, simply by uterine 
contraction. In such cases, the form of the tumour is usually 
clearly defined, sometimes appearing perfectly round like 
a musket-bullet or billiard-ball, and sometimes nodulated. 
Doubtless the direction taken by the fibres is the most influ- 
ential cause in modifying the form and properties of the 
surface. 

All perfect fibrous tumours contain vessels ; it is only in 
very small tumours of this kind that I have been unable to 
discover them. It is, however, probable that the isolated 
tumours just mentioned are non-vascular, and that they 
receive the blastema necessary to their growth from the 



FIBROUS TUMOURS. 



219 



vessels of the neighbouring parts. It appears, however, pro- 
bable that some, if not all of these tumours, have in some of 
their stages possessed vessels, but that subsequently in pro- 
portion as the connection of the tumour with its surrounding 
parts became slighter, they were gradually obliterated, and at 
last entirely disappeared. 

Usually, however, the vessels of fibrous tumours are few 
in number, and it is only in rare instances, or in cases where 
changes occur of which we shall speak presently, that such 
tumours are rich in vessels. But that pathological formations 
of fibrous tissue may be combined with vascular formation, 
we have already seen in our remarks on vascular tumours, 
(see p. 207). But these vascular tumours are essentially dis- 
tinguished in their entire character from proper fibrous tumours. 

We have likewise already spoken of the combination of 
fatty and fibrous tumours. This combination presents the 
most manifold varieties. Sometimes the two elements are so 
intimately connected, that only microscopic examination can 
distinguish them. In other cases, and indeed most com- 
monly the two elements are arranged in large groups, easily 
discernible with the naked eye, so that the same tumour 
examined at one part, will sometimes appear as a fatty 
tumour, examined at another, as a fibrous tumour, and at a 
third, as a tumour composed of the combined elements. 

The other principal histological variety of fibrous tumour is 
characterised by the fact that it contains no perfectly formed 
fibres, but rather presents the appearance of an amorphous 
mass, in which a more or less strongly expressed tendency to 
fibrillation is discernible. These tumours exhibit under the 
microscope a mass entirely amorphous, amorpho-granular, or 
amorpho-fibrous, in which oil-globules or fatty granules are 
sometimes found. By the application of acetic acid the mass 
becomes transparent, and more or less clearly exhibits nuclei, 
which resemble those of the fully developed fibrous tumours. 
Between this almost amorphous mass, and the perfect fibrous 
tumours, there is every intermediate stage. These amor- 



202 



PATHOLOGICAL EPIGENESES. 



phous fibrous tumours have a lardaceous appearance, and the 
transition-forms springing from them, are firm and similar to 
cartilaginous tissue, with a milk-white or yellow colour. 
They are never rich in vessels, and sometimes altogether 
devoid of them. They must be regarded as fibrous tumours, 
whose histological development is yet at a low stage, or whose 
substance is incapable of development carried to any high 
degree. They may, however, be known to belong to the 
class of fibrous tumours by the fact that, in one and the same 
tumour, there are found parts which are entirely amorphous, 
alternating with others which exhibit fibrous tissue. It is 
highly probable that a large number of fibrous tumours arise 
from an amorphous solid blastema, and that consequently 
most fibrous tumours at an early stage of their development, 
exhibit this amorphous character. 

The chemical relations of fibrous tumours present many 
differences. The perfect fibrous tumour yields gelatin analo- 
gous to that of areolar tissue (colla) , while from those consist- 
ing of simple interlaced muscular fibre, no gelatin is yielded 
on boiling. Neither by boiling can we obtain gelatin from the 
fibrous tumours which are yet undergoing development, and 
are amorphous. Accurate ultimate analyses of these tumours 
are still wanting. 

Their occurrence. The various forms of fibrous tumour 
occur in all parts of the body which in the normal condition 
contain much fibrous tissue ; on the external skin and the 
mucous membrane, as cases of hypertrophy, condylomata, 
warts, and polypi ; in the subcutaneous cellular tissue ; upon 
the periosteum and in the interior of the bones ; on the mus- 
cular coat of the intestinal canal, in the muscular tissue of 
the uterus, and in the ovary ; in the cavities of the thorax 
and abdomen, where they often reach a very considerable 
size ; and in the cavity of the skull, where they frequently 
arise from the dura mater. And here the fact is exemplified, 
that when fibrous tumours arise in parts where areolar tissue 
prevails, they consist principally of more or less fully deve- 



FIBROUS TUMOURS. 



221 



loped fibres of areolar tissue, whilst tumours consisting of 
simple muscular fibre, are only found in those parts which 
consist in the normal condition of simple muscular fibre. 

Of the causes leading to the origin of these tumours, the 
same may be repeated as was formerly said with regard to 
fatty tumours. They are sometimes congenital, but more 
frequently appear after birth, and often, indeed, not until an 
advanced period of life : this is especially the case with fibrous 
tumours of the uterus. Their first germ is probably always 
dependant on the deposition of an amorphous blastema (ex- 
travasated blood and coagulated fibrin) which, in accordance 
with the law of analogous formation, they convert into fibrous 
tissue, and the occasion of this deposition is very usually a 
mechanical injury, as a blow, a thrust, or fall. But the 
cause when the mischief occurs in deep-seated parts is often 
beyond the power of art to trace. Experiments on animals 
are very well calculated to throw light on the origin of these 
tumours. I will here quote one case which appears to me 
very instructive in this point of view. I injected several 
ounces of an aqueous solution of hydrosulphate of ammonia 
into the abdominal cavity of a large dog, through a small 
wound in the linea alba, and then immediately closed the 
orifice by a suture. For the first quarter of an hour after the 
operation, the animal appeared to suffer violent pain ; within 
an hour, however, he recovered and remained afterwards as 
well as if nothing had happened. At the expiration of 
twenty-four hours he was killed. There was an amorphous 
exudation of coagulated fibrin on several convolutions of the 
intestinal canal under the peritoneum, and blood was extra- 
vasated between the muscular and serous coats. On the 
anterior surface of the stomach there was a coagulum of blood 
of the size of a hazel nut, surrounded by a thick layer of 
coagulated fibrin, and firmly attached to the outer wall of the 
stomach. I am thoroughly convinced that this coagulum 
w T ould, in time, have been converted into a fibrous tumour, if 
the animal had not been killed. I had frequent opportunities 



222 



PATHOLOGICAL EPIGENESES. 



of making similar observations. This appears to illustrate 
the probable origin of fibrous tumours in man, at least of 
such as occur in the stomach, the intestinal canal, and more 
especially in the uterus, where there are frequent opportu- 
nities for the formation of coagula and of fibrinous exudations. 
In proportion to the smallness of the exudation, is the in- 
fluence of the surrounding normal fibrous tissue, and the faci- 
lity with which the exudation can be organized : consequently 
the most perfectly formed fibrous tumours are cases of hyper- 
trophy, where the exudation is gradual and never in large 
quantities ; and conversely, when the exudation is in large 
quantity, it is probable that the amorphous fibrous tumours 
are formed. When the tumour has once arisen, it is easy to 
explain its further growth. In those tumours which are pro- 
vided with vessels, this growth takes place not simply at the 
surface, but through the entire mass. Moreover, in very 
large tumours we observe on making a thin section, fibres in 
the course of development — caudate cells. 

The further progress of fibrous tumours is very similar to 
that of fatty tumours. They are in themselves throughout 
their whole course non-malignant, but they may in various 
ways become injurious, as by pressure on nerves, vessels, 
&c. ; or by their size which often becomes very considerable, 
such tumours attaining a weight of twenty pounds or even 
more. They then distend the skin, cause its veins to swell, 
and give rise to inflammation, suppuration, and ulceration. 
Many fibrous tumours, especially those seated in the uterus, 
ossify ; that is concretions are formed in them — unorganized 
depositions of calcareous salts, which are often falsely regarded 
as newly formed osseous substances. Of these we shall speak 
in our observations on concretions. 

We shall presently notice the combinations of fibrous 
tumours with malignant epigeneses. Though it is impossible 
to divide fibrous tumours into proper species, yet the follow- 
ing forms and transitions may be distinguished. Perfect or 
fully developed fibrous tumours approach nearly to areolar 



FIBROUS TUMOURS. 



223 



tissue, to normal fibrous tissue, or to simple muscular tissue. 
They exhibit transitions : 

1. Into the amorphous forms of fibrous tumours. 

2. Into vascular tumours (rarely). 

3. Into fatty tumours. All these transitions arise spon- 
taneously from the above form. 

4. Into cartilaginous and osseous tumours. 

5. Into encysted tumours, through the compound Cystoid 
— in a manner to be described, when we come to encysted 
tumours. 

6. Into malignant tumours, of which hereafter. This 
transition is of especial importance, but often very difficult to 
diagnose. 

7. Of other transition-forms we shall speak in the appendix 
to the tumours. 

In these as in fatty tumours, it is very difficult to understand the 
earlier classifications founded on external signs.* To this class belong, 
as has been already mentioned, some forms of hypertrophy of the exter- 
nal skin and mucous membrane — condylomata and polypi, desmoid, some 
cases of steatoma and of sarcoma, the greater number of cartilaginous 
tumours, (Chondroid), many cases of osteosarcoma, and fibrous tumours. 
Miillerf distinguishes tendinous and albuminoid fibrous tumours ; the 
former are fully formed, and on boiling yield gelatin ; the latter are either 
not fully developed or consist of simple muscular fibre, and on boiling 
yield no gelatin. For information with regard to the chemical properties 
of these tumours, we have to thank J. Miiller and Valentin for their 
extensive investigations. Miiller has shown that we may distinguish 

* Some of the literature of the subject, (that namely referring to 
steatoma) has been already given in p. 213. To the works there named 
we may add: J. Miiller in his Archiv. for 1836, Jahresber. ; J. F. 
Meckel's Patholog. Anatomie, vol. n. Part n. p. 165, 242; Gluge's 
Atlas d. pathol. Anatomie, Part iv. Fasergeschwiilste ; G. Valentin 
in his Repertorium, 1837, p. 270. 

Several histological delineations are given by Miiller; see Plates ir s 
and in. of Dr. West's translation. The above literature has relation 
chiefly to the peculiar form of fibrous tumour occurring in the uterus, 
and we shall return to this subject in the special department, when 
speaking of that organ. 

t Archiv. 1836, Jahresbericht. 



224 



PATHOLOGICAL EPIGENESES. 



fibrous tumours into those which yield gelatin, and those which do 
not yield it. Valentin endeavoured to prove that the elementary 
matter of fibrous tumours in the uterus is coagulated fibrin and not 
albumen, but the reactions on which he founded his opinions, 
cannot at present be regarded as decisive. 

Decisive ultimate analyses are still desiderata. It cannot be doubted 
but that in a chemical point of view, the laws regulating the develop- 
ment of these tumours, correspond with those influencing the develop- 
ment of the normal fibrous tissues. 

FOURTH GROUP. 

TUMOURS WHICH CHIEFLY CONSIST OF CARTILAGINOUS TISSUE. 

Cartilaginous Tumours. 
Tumours into the composition of which cartilaginous tissue 
enters, are of much less frequent occurrence than those 
hitherto described ; they are, indeed, rarer than we might 
be led to judge from physical characters alone; since, 
as already stated, many swellings apparently cartilaginous 
belong, in reality, to fibrous tumours. Most frequently true 
cartilaginous tumours appear as hypertrophies and abnormal 
growths of bones — as callus, exostosis, &c. They then con- 
sist of true cartilaginous tissue, but only in a state of tran- 
sition, since they gradually pass into osseous substance, and 
thus into osseous tumours in the manner described in page 198. 
Isolated cartilaginous tumours occur more rarely, and it is 
only within a few years, and chiefly by means of J. Muller's # 
elaborate investigations, that they have been known with any 
degree of accuracy and designated by the term, enchondro- 
mata. We must now proceed to the closer consideration of 
these tumours. 

Enchondroma appears under three distinct forms : in the 
bones, either 1 , in the interior ; or 2, on the surface covered by 
the periosteum ; and 3, in soft parts, as for instance, glandular 

* Compare J. Muller iiber d. fein. Bau d. krankh. Geschwulste, 
p. 31, &c. ; or West's translation, p. 96, &c. ; Dr. Jac. Herz, de en- 
chondromate, Erlangse, 1843 ; G. Gluge, Atlas der pathol. Anatomie, 
Part 4. 



CARTILAGINOUS TUMOURS ENCHONDROMA. 



225 



organs. It forms a roundish, and generally smooth tumour 
of variable size, which on a section being made allows even 
the unaided eye to recognize two distinct constituents, one 
fibro-membranous, and the other gray, transparent, and soft, 
resembling firm jelly or softened cartilage. The latter element 
shows under the microscope roundish or elliptic cells varying 
from the 150th to the 50th of a line in diameter, and sometimes 
even larger, which enclose a granular nucleus ranging from 
the 200th to the 300th of a line in diameter. These some- 
times occur as primary cells, and contain several nuclei, or 
even one, two, or three more recently formed and proportio- 
nally smaller cells in their interior.* Besides the nuclei we 
also occasionally observe irregular, oblong, pointed bodies 
which are suggestive of bone-corpuscles.f These cells resist 
the action of acetic acid better than most other animal cells, 
and, in general, are but loosely connected together, being 
readily isolated by slight pressure : in some more rare cases 
there exists between them, as in normal true cartilage, an 
amorphous firm intercellular substance ;J the entire mass in 
this case is firmer, and in its physical characters more closely 
resembles true cartilage. 

The fibro-membranous portion appears under the micro- 
scope as fibrous tissue, arranged into sheaths or nets, in the 
meshes of which is lodged the cellular substance. The latter is 
sometimes of irregular form, but usually globular, and then 
frequently protrudes upon the surface of the tumour in the 
form of rounded eminences. § 

Hence, in the rarer cases, in which a firm, amorphous, 
intercellular substance exists between the cells (cartilage- 
corpuscles) enchondroma, viewed histologically, resembles 
true cartilage ; in the more frequent cases, on the other hand, 

* Compare J. Miiller, op. cit. tab. in. fig. 4, 5, 6, 7. 
f Miiller, op. cit. tab. in. fig. 8. 
I Herz, op. cit. fig. 2. 

§ J. Miiller, op. cit. tab. i. fig. 12; G. Gluge, op. cit. tab. i. fig. 1, 2. 
VOL. I. Q 



226 



PATHOLOGICAL EPIGENESES. 



in which the cartilage-corpuscles are more isolated, and have a 
fibrous tissue between them, it presents a greater resemblance 
to fibro-cartilage, with this difference, however, that in nor- 
mal fibre-cartilage the cartilage-corpuscles are more isolated 
and scattered in a thick net of fibrous tissue, whilst in 
fibrous enchondroma masses of cartilage-cells lie between 
bundles of fibrous tissue, just as in steatoma accumulations 
of fat-cells are lodged between masses of fibre. We may, 
therefore, regard fibrous enchondroma as a combination of 
the cartilaginous with the fibrous tumour. 

In its chemical relations enchondroma resembles ordinary 
cartilage before ossification, i. e. upon boiling, it generally 
yields chondrin. This was obtained by J. Miiller from en- 
chondroma of the bones and of the testicle ; on the other hand 
a much softer enchondroma of the parotid gland yielded, upon 
boiling, not chondrin, but ordinary gelatin (colla). From 
this it would appear that chemical differences exist, upon 
which we require to be further enlightened. 

The three above mentioned forms of enchondroma depend- 
ing upon locality present, also, in their structure certain 
differences which deserve an especial consideration. 

A. Central enchondroma in the interior of the bones. 
This form, the most frequent of all, usually appears in the 
metacarpal and metatarsal bones, and in the phalanges of the 
hand and foot, as rounded, smooth tumours of variable size, 
encased in a vesicular, expanded, osseous cortex. The very 
characteristic external form of these tumours will be best 
understood from illustrations.^ The tumour is found, upon 
closer investigation, to be enclosed in a bony case, which 
varies in thickness in different spots, but is not unfrequently 
absent at some points, as if the tumour had burst through 
its wall. This bony covering arises less from the mechanical 
distension and expansion of the tumour than, doubtless, 

* J. Muller, op. cit. tab. iv. fig. 1, 2, 3 ; Herz, op. cit. fig. 1, 3, 
5, 6 ; Gluge, op. cit. tab. n. fig. 2. 



CARTILAGINOUS TUMOURS — ENCHONDROMA. 227 



from the circumstance that new bone is constantly formed 
upon its surface during growth, but that its deposition is 
modified in arrangement by the presence of the tumour. 
A section of the tumour shows the elements formerly 
described — portions of soft cartilaginous substance inter- 
laced by bundles of fibres. Here and there appear also in its 
interior portions of bone — remains of the spongy substance of 
the original bone. # 

b. Peripheral enchondroma of the bones agrees with the 
former variety, insomuch as it also originates in the bone : 
it is formed, however, not in the interior, but on its surface, 
and has, therefore, no bony sheath, being covered only by 
the periosteum. Its form is less regularly round, and its 
surface is rendered rugged and uneven by the separate, 
rounded cartilaginous formations, which protrude as distinct 
nodules varying from the size of a pea to that of a cherry.f 
The internal structure does not differ from that of the former 
variety, small portions of bone being, likewise, occasionally 
found between the fibres and the cartilage-cells. This form is 
principally observed in flat bones, namely, the ribs and the 
cranial and pelvic bones, seldom in the cylindrical bones. 

c. Enchondroma of soft parts is much rarer, and was 
observed by J. Muller only four times in thirty-six cases of the 
disease, once in the parotid gland, once in the mamma, and 
twice in the testicle, thus occurring only in glandular parts. 
This variety is distinguished by containing no bony matter, 
either as an external covering or in its interior, and by the 
fibrous tissue intervening between the cartilage-cells, being 
sometimes replaced by a more amorphous intercellular sub- 
stance, so that the mass closely resembles true cartilage. 

The fibrous substance of enchondroma contains but few 
vessels. These tumours are non-malignant and unaccompa- 
nied by pain, and are so slow in their development that they 

* Gluge, op. cit. tab. n. fig. 2. 
f Gluge, op. cit. tab. i. fig. 1, 2. 

Q 2 



228 



PATHOLOGICAL EPIGENESES. 



often exist and increase for ten or twenty years, attaining a 
considerable size without materially incommoding the patient. 
Gluge describes a tumour of this kind, which, on extirpation, 
weighed nine pounds and a half. # They may, however, 
when large, like the non-malignant tumours formerly described 
inflame and ulcerate, and become dangerous from the quantity 
of the discharge. 

The origin of enchondroma can often be referred to mecha- 
nical injuries, as contusions, bites, &c. which appear more 
capable of giving rise to this species of tumour in childhood 
than in adult life. Enchondroma is not, however, in all 
cases referrible to a local injury ; sometimes it occurs in several 
parts of the body at the same time, resulting from a general 
or constitutional cause. There can be no doubt that in en- 
chondroma of the bones, the law of analogous formation per- 
forms a determinate part in the organization of the exudation ; 
but it should not be forgotten, that, in these cases, the carti- 
laginous substance of the enchondroma does not correspond 
altogether with true cartilage. At present we cannot even 
hazard a conjecture as to the originating cause of enchon- 
droma in glandular organs. 

From what has been stated, it will be seen that there exist 
two distinct forms of cartilaginous tumour : cartilaginous 
exostosis and enchondroma. They sometimes so closely 
resemble each other, that they can only be distinguished by a 
close anatomical investigation. 

Enchondroma sometimes presents, in its interior, cavities 
filled with fmid,f and thus passes into the category of cyst 
formations ( Cystoid) . 

In a diagnostic point of view, the transition from 

* Op. cit. explanation of tab. i. 

f Compare Gluge, op. cit. explanation of tab. i. It is possible that 
two of the cases described by Frogley (Medico-chirurg. transactions, 
1843, p. 133) as osteo- sarcoma of the femur belonged to this category; 
in consequence, however, of there having been no microscopic exami- 
nation, it is impossible to decide with certainty. 



CARTILAGINOUS TUMOURS — -ENCHONDROMA. 229 



enchondroma to fibrous tumour is highly interesting. 
This is accomplished, in enchondroma of the bones, by 
the gradual increase of the fibrous part, the cartilaginous 
portion diminishing in the same ratio. Indeed, many 
tumours which, judging from the external form, might 
be taken for enchondromata, in reality consist entirely of 
more or less developed fibrous tissue, and contain no carti- 
laginous substance. The external form and appearance of a 
tumour are, therefore, not sufficient evidence of its being an 
enchondroma, a microscopic investigation being essential to a 
certain diagnosis. 

Enchondroma, the most important of the forms of tumour belonging 
to this class, was only made known to us a few years ago by the va- 
luable investigations of J. Miiller. These tumours were previously 
grouped with many others occurring in the bones, and designated by 
the various names of atheroma nodosum, spina ventosa, osteosarcoma, 
and osteosteatoma ; it is not possible, therefore, from the name alone, 
to recognize the previously observed enchondromata. In the living 
subject before operation it is often difficult to distinguish cartilaginous 
exostosis from enchondroma. The diagnosis is easier on making a sec- 
tion of the tumour, when the internal structure — the soft cartilaginous 
portion with the fibrous layer — enables us to recognize the microscopical 
characters of enchondroma. True enchondromata do not ossify, although 
the ramifying corpuscles which they occasionally exhibit, are strongly 
suggestive of osseous particles.* The great resemblance which many 
fibrous tumours bear to enchondroma demands especial attention in a 
histological point of view, and requires great caution in the diagnosis, 
although the distinction between true enchondromata and fibrous 
tumours is of little consequence to the practical surgeon, since both 
forms of tumour appear to exercise an entirely similar action on the 
human organism. I have examined some tumours (one on the pelvis, 
one on the toe, and two on the hand) regarded as enchondromata 
and which in their external characters they perfectly resembled, espe- 
cially the one figured by Herz (fig. 9) ; they showed no trace of 
cartilage- corpuscles, but consisted entirely of more or less developed 
fibrous tissue. These observations might lead us to judge that apparent 
enchondroma is almost as frequent as the true form, or at all events 
must induce us to exercise caution in the diagnosis, and forbid us, 
without minute investigation, to characterize a tumour of which the 

* Miiller, Plate in, fig. 8. 



230 



PATHOLOGICAL EPIGENESES. 



bony case alone remains, as true enchondroma. For further informa- 
tion concerning the relation of enchondroma to other tumours occurring 
in the bones, as well as concerning cartilaginous exostosis, I must 
refer to the chapter on the bones, in the special part of the work, 

FIFTH GROUP. 

TUMOURS CONSISTING CHIEFLY OF OSSEOUS SUBSTANCE. 

Osseous Tumours. 

Tumours, in which bony tissue is morbidly formed, present 
in individual cases such great differences in form and struc- 
ture that it is impossible, as in most of the forms of 
tumour which have been considered, to give a general descrip- 
tion of them. They usually appear in or upon bones, and 
their peculiarities can only be clearly elucidated by a compa- 
rison with other pathological changes which take place in the 
bones themselves. We will, therefore, leave their detailed 
consideration to the special part, and confine ourselves here to 
some of their general relations. 

It is especially important to distinguish the true from the 
false or apparent osseous growth. The former presents in its 
histological and chemical relations, all the characters formerly 
described (see page 199) as appertaining to true bone; the 
latter consists of an unorganised deposition of calcareous salts 
between different histological elements, and belongs to the 
concretions, under which head it will be treated of at greater 
length. Most of the so termed ossifications, including those 
which occur in tumours, belong also to this class, and are 
not true bony structure. 

The tumours in which true osseous substance appears, 
either consist entirely, or for the most part of newly formed 
bone ; or contain it in smaller proportion, forming, according 
to the terminology which we have hitherto adopted, combina- 
tions of the osseous with other forms of tumour. 

To the former belong the osseous formations unconnected 
with normal bone, which most frequently occur in fibrous 



OSSEOUS TUMOURS. 



231 



membranes, especially the dura mater, in tendons, (the sesamoid 
bones) and occasionally in the eye (Valentin) ; and the osseous 
tumours which are connected with normal, or diseased bone, 
and known as exostoses. As they arise, like normal bone, from 
true cartilage, they sometimes, before their perfect ossifica- 
tion, consist in part of true cartilaginous substance, and are 
thus connected with the cartilaginous tumours. 

Moreover tumours which consist only in part of true 
osseous substance, appear from the observations hitherto made, 
almost always to arise from diseased bone, but, in addition to 
the newly formed morbid osseous matter, there are also pro- 
duced other histological elements — fibrous tissue, vessels, car- 
tilage, fluids enclosed in cysts, and even malignant elements, 
as encephaloid and tubercle. The newly deposited bone forms 
very irregular masses, generally of a porous structure, which 
project in the form of plates, or spicula amongst the other 
elements of the tumour, or form cellular spaces enclosing 
these elements. The newly formed osseous substance is 
either connected with the original bone, which, upon the 
removal of the soft part by maceration, appears covered with 
bony excrescences, as in true exostosis ; # or it lies in loose 
patches in the soft parts, and is lost by maceration. It 
sometimes forms only a small part of the whole tumour, 
sometimes more than half. The latter cases are connected 
with the exostoses. 

The great variety of these compound bony tumours renders 
it extremely difficult to characterise and classify the indivi- 
dual forms ; since almost every case hitherto described dif- 
fers more or less from the others. We cannot, therefore, 
speak of distinct species or varieties of these tumours, but 
must follow, as well as possible, the method which we 
have hitherto adopted, and regard the individual forms as 
combinations of the bony tumour with other elements ; thus it 

* A very characteristic preparation of this kind is delineated by 
Weidmann : Annotatio de steatomatibus, tab. v. 



232 



PATHOLOGICAL EPIGENESES. 



may be combined with the fibrous tumour, the vascular 
tumour, the cartilaginous tumour, the fatty tumour (?), the 
gelatinous tumour, the encysted tumour and the cystoid, and 
with all the malignant forms of tumour. The subject is ren- 
dered more intricate by the circumstance that there may 
occur not only one of these combinations but several, indeed 
almost all simultaneously in the same tumour. 

Causes and mode of origin of osseous tumours. From the 
above observations it can hardly be doubted that the forma- 
tion of bony substance in tumours follows the same laws 
which hold good in the development of bone generally, and 
which have been already discussed, although this structural 
process has, as yet, been directly observed in only a few 
cases. It may, moreover, be safely assumed that the cytoblas- 
tema of the new osseous structure is a fibrinous fluid derived 
from the blood. The increased exudation, occurring some- 
times rapidly and abundantly, sometimes more slowly but 
therefore continuing the longer, which gives rise to the 
pathological formation of bone may be occasionally ascribed to 
external causes — mechanical injuries as a blow, kick, fall, 
&c. ; at other times it proceeds insidiously from constitu- 
tional or local internal causes, and is frequently only percep- 
tible by its consequences. In the metamorphosis of the blas- 
tema into bony substance we find in many cases the law of 
analogous formation in operation, acting sometimes alone, at 
other times in opposition to a tendency to malignant forma- 
tions. If we consider that normal bone itself is a very 
complicated structure, and, besides the proper osseous sub- 
stance, contains medulla, vessels, periosteum, in short very 
different histological elements, it will be apparent that the 
law of analogous formation serves to explain many compound 
forms of osseous tumour. It should, however, be borne in 
mind, that all such laws admit of only a general application, 
and are frequently insufficient to the elucidation of a special 
case. The peculiar causes of the osseous formations which 



MELANOTIC TUMOURS. 



233 



are unconnected with bone — as for instance those of the dura 
mater — remain entirely unknown. 

Osseous tumours are invariably non-malignant : nevertheless 
when combined with other elements they may be destroyed 
by ulceration, &c. and this destructive process may proceed in 
the form of caries or necrosis to attack the newly formed 
osseous tissue itself ; this is especially the case with the bony 
tumours combined with malignant elements. 

Our knowledge of the bony tumours is still very imperfect, especially 
with regard to their histological relations.* The classification and 
nomenclature of the tumours belonging to this group are also very 
confusing ; there belong to it the different species of exostosis, some 
of the osteo- sarcomata, osteo-steatomata, some cases of spina ventosa, 
the osteo-phyte of Gluge, and the osteoid of Miiller. The more minute 
characteristics of all these tumours will be given in the special part. 

SIXTH GROUP. 

TUMOURS ENTIRELY OR IN PART CONSISTING OF DARK PIGMENT. 

Melanotic Tumours. 

In many tumours there occurs a dark pigment as a more or 
less prevalent constituent. This pigment appears, however, 
so far as the still scanty histological investigations of such 
tumours enable us to judge, to present very different charac- 
ters. 

In many cases it consists of dark (brown or black) granules 
enclosed in more or less distinct rounded or elongated 
cells, sometimes it is altered blood-pigment, and occasio- 

* The special literature is given in the chapter on the morbid changes 
in bone. In addition to the references previously given, respecting the 
morbid epigenesis of osseous tissue, we may notice : G. Gluge, Atlas der 
patholog. Anatomie, Part n. (osteophyten) ; and J. Miiller in hisArchiv. 
1843. Ueber ossificirende Schwamme oder Osteoid- Geschwiilste, p. 396, 
&c. ; in both places there is a copious bibliography of the earlier writers. 



234 



PATHOLOGICAL EPIGENESES. 



nally it is composed of granules of sulphuret of iron. The 
pigments of melanotic tumours admit, therefore, of distinction 
into the same varieties as were formerly pointed out in the 
pathological epigenesis of granular pigments generally, (see 
p. 196) namely into true and false melanosis, the latter further 
resolving itself into that produced by altered blood-pigment, 
and that consisting of deposited sulphuret of iron. 

The pigment is never the sole constituent of melanotic 
tumours ; it forms only a portion of the whole, and is scat- 
tered amongst other histological elements, such as perfectly 
developed or comparatively amorphous fibrous tissue, vessels 
(which, however, are never abundant), and malignant forma- 
tions, as tubercle, encephaloid, and scirrhus. Melanotic 
tumours are, therefore, always compound. The pigment- 
molecules are sometimes equably distributed amongst the 
other elements, at other times accumulated at particular 
points : the tumour, therefore, appears sometimes equally 
dark throughout, sometimes spotted, and sometimes presents 
alternating light and dark strata. In true melanosis the 
colour is brown, of a bistre tint, blackish, or, if only a little 
pigment is present, gray ; in the false variety depending upon 
sulphuret of iron, it is slate-gray, or greenish black : in that 
resulting from altered blood-pigment it is blue, violet, or 
brownish black. The discrimination of these three varieties 
is easily accomplished by means of the microscope with the 
aid of chemical reagents, according to the rules given in 
pp. 192 — 5. Occasionally the melanotic colour which appears 
in tumours in the form of spots, depends upon decomposed 
blood in the interior of vessels (veins). 

Melanotic tumours have been observed upon almost every 
part of the body, in the eye, the female genital organs, the 
lungs, liver, &c, also upon the external surface, the skin, 
subcutaneous cellular tissue, &c. Sometimes they appear 
solitary, sometimes in great numbers ; and gradually extend- 
ing over the whole body, form a general disease terminating 



MELANOTIC TUMOURS. 



235 



in the death of the patient. They occur more frequently in 
the female than in the male sex. 

The progress of melanotic tumours depends upon their com- 
binations. True melanosis is of itself non-malignant, and so 
is its combination with fibrous tumour ; on the other hand its 
combination with malignant elements is naturally malignant. 
False melanosis is generally injurious from its very nature, 
since its occurrence presupposes an important decomposi- 
tion of the fluids ; when, however, it remains localised it is of 
less importance. 

The causes producing them vary with the nature of the 
tumour : in false melanosis they are usually of a chemical 
nature, and can frequently be recognized, as has been already 
shown. 

The causes of true melanosis are obscure, although 
the law of analogous formation appears, at least occasionally, 
to perform a conspicuous part ; thus melanotic tumours in the 
eye usually arise from the choroid, and melanotic tumours of 
the skin in the Rete Malpighi, in which the formation of pig- 
ment is a very frequent phenomenon. 

Our knowledge of melanotic tumours is still very deficient : every 
tumour which was entirely or in part of a dark colour, has been arranged 
under this division, and thus the most different structures have been 
promiscuously thrown together. A clear insight into the nature of these 
tumours can be expected only from more extended histological investi- 
gations : this is especially the case with those forms which, having 
spread over the entire body, have become constitutional, and which, 
hitherto have not been examined in a sufficiently accurate manner : and 
hence a more minute description of the individual forms, and a discus- 
sion on the question of their malignity or non- malignity, with a critique 
of the views hitherto adopted of their mode of origin, are quite unneces- 
sary.* The chemical relations of melanotic tumours may be regarded 

* The most important literature is comprised in : Carswell's Patholo- 
gical anatomy. Melanoma; Schilling de Melanosi, 1831 ; Gluge, Atlas 
der pathol. Anatomie, Part in. ; Cruveilhier, Anatomie pathologique, 
liv. xix. and xxxn. fol. plates, Paris, 1830 — 42. 



236 



PATHOLOGICAL EPIGENESES. 



as still quite unknown. A portion of a melanotic tumour of the brain 
analysed by A. Vogel, jun. yielded :* 

Carbon . . 49.885 

Hydrogen . . 7.156 

Nitrogen . . 23.784 

Oxygen . . 19.175 

100.000 

This analysis differs very considerably from that given in page 192 
of the colouring matter from melanotic lungs. In that case, how- 
ever, the histological examination was totally neglected, and there- 
fore we cannot now precisely determine what was analysed, so that 
unfortunately it is of no value to pathological anatomy. 

SEVENTH GROUP. 

TUMOURS CONTAINING A GELATINOUS SUBSTANCE. 

Gelatinous Tumours. 

In many tumours there occurs a viscid, gelatinous sub- 
stance, partly infiltrated amongst the other firm elementary 
tissues, and partly contained in appropriate spaces or cavities, 
sometimes in such abundance and so greatly exceeding the 
other elements, that the tumours may, with great propriety, 
be termed gelatinous. The elements co-existing with the 
gelatin in these tumours are of very various kinds, generally 
fibres, vessels, and sometimes even cartilaginous tissue, so 
that these tumours may be considered combinations of the 
fibrous tumour, enchondroma and encysted tumour; even 
cancer-cells occur conjointly with this gelatin, and the most 
frequent form of gelatinous tumour is the so named gelatinous 
cancer (colloid). 

This substance is always transparent and colourless, some- 
times fluid, resembling thick mucus, at other times firmer 
like half softened jelly. Under the microscope it appears 



* Munchner gelehrte Anzeigen, 1844, No. 143, p. 108, &c. 



GELATINOUS TUMOURS. 



237 



completely amorphous and so perfectly transparent, that it is 
not easy to see it. In the cases which I have examined, it 
coagulated, on the addition of acetic acid, into a colourless, 
striated, amorphous mass : the same reaction was caused by 
sulphate of the protoxide of iron, infusion of galls and (to a 
less degree) by alum, alcohol, and bichloride of mercury. 
Nitric acid and nitrate of silver caused only a slight turbidity 
which was doubtless dependant on the presence of albumen. 
It was insoluble both in cold and boiling water. Its quantity 
was too small to admit of ultimate analysis ; until, however, 
this is effected nothing certain can be determined concerning 
its chemical constitution. 

It may be inquired whether the gelatin possesses the same 
properties in all tumours. In six cases, which I have now 
investigated, its character seemed perfectly identical, and it 
presented the above reactions. I consider this substance 
which in its chemical and physical characters is analogous to 
mucus and pyin (as far as its properties are known) to be 
non-malignant ; when a tumour is composed of it, as in the 
gelatinous cancer (colloid), it appears to me that this results 
rather from mechanical causes — distension of the tissues by 
the deposited mass, &c. than from a specific action, as in the 
strictly malignant tumours. Nothing can as yet be stated 
with certainty concerning the origin of this substance ; it 
arises, however, in all probability like normal mucus, from 
changed protein-compounds of the blood. The elucidation of 
these relations can only be expected when the chemistry of 
the metamorphosis of tissues shall be better known than it is 
at present. 

Under the head of gelatinous tumour, J. Miiller has described Collo- 
nema, a peculiar tumour which I myself have not yet seen and which I 
shall notice here,* since I do not perceive where else it can be included. 
According to him, it consists of " a remarkably soft gelatiniform tissue, 
which trembles upon touching. The organised elements form very 



* Archiv. 1836, Jahresber. 



238 



PATHOLOGICAL EPIGENESES. 



scanty bundles of fibres and vessels. The chief mass consists of gray 
globules, some of them much larger than blood-corpuscles. Crys- 
talline needles lie scattered in immense numbers throughout the whole 
tumour : they consist of a peculiar, non-fatty animal matter, and can 
be readily recognised by the microscope in every part of the tumour. 
They are insoluble in acids and alcalies ; the latter by dissolving the 
non- crystalline portion of the tumour, isolate the needles and render 
them more apparent. Upon boiling a portion of the tumour in water, 
the crystals are destroyed ; at the temperature of the body, how- 
ever, they remain unchanged. They are insoluble in hot spirit, but 
dissolve in boiling ether. This tumour has been observed once in the 
brain, and once in the female breast ; the crystals were similar in both 
cases : the uncrystallized mass, on the other hand, was different. The 
decoction of the tumour from the brain was not precipitated by tannin, 
spirit, mineral acids, acetic acid, ferro-cyanide of potassium, alum, sul- 
phate of iron, acetate of lead, or bichloride of mercury, and, therefore, 
most closely corresponded with ptyalin, or the mucus of English 
authors ; the decoction of the tumour from the breast, on the contrary, 
contained a very small quantity of casein, which was precipitated by a 
drop of acetic acid and by its other ordinary tests." 

EIGHTH GROUP. 

TUMOURS ENCLOSED IN A PROPER CYST. 

Encysted Tumours. 

These tumours are peculiarly distinguished by being en- 
closed in a proper membranous sac which isolates them from 
the surrounding parts. In the numerous differences which 
the individual forms of encysted tumour present, this cha- 
racter, however, is not always distinctly marked, and there 
occur many intervening forms between this and other tumours. 
We discriminate, therefore, between the true, simple encysted 
tumours (tumores cystici) and the compound — combinations 
of this with other forms of tumour (cystoid). 

A. The true, simple encysted tumours not only possess a 
perfectly closed membranous sac, but it is also essential to their 
character, that the contents of this sac are either not at all, 
or only very imperfectly organized, and show no organic con- 
nection with the sac itself. This forms the distinction between 



ENCYSTED TUMOURS. 



239 



encysted tumours and the enclosed fatty and fibrous tumours 
formerly described, in which the envelope, consisting of 
areolar tissue, throws out organized elongations, and pro- 
cesses not only into the substance of the surrounding parts, 
but even into that of the tumour itself ; thus not so much 
separating the tumour from the surrounding parts, as form- 
ing a medium of connection between them. 

This form of encysted tumour presents many varieties both 
with respect to the state of the cyst, and the nature of its 
contents. It admits of being grouped into two tolerably 
well characterized subdivisions. 

The first embraces encysted tumours with aqueous or 
serous contents, which approximate more or less to the fluids of 
serous and fibrinous dropsy, and sometimes entirely corres- 
pond with them. I will call them serous cysts, lifeless hyda- 
tids. These also present different forms, most of which 
scarcely deserve the name of encysted tumours, and would 
more properly be regarded as modifications of a local true or 
false dropsy. Their principal forms are the following : 

1 . When, in a local circumscribed serous dropsy, the fluid 
is effused in a part consisting of lax areolar tissue, or under a 
thin membrane, as for instance a serous membrane, it forms 
a vesicle resembling the blisters so frequently observed upon 
the skin after burns or vesicants, in erysipelas bullosum, &c. 
In this case the cyst is not a new structure, but consists of 
normal tissue distended by the dropsical fluid ; moreover, it 
does not form a symmetrical, perfectly closed sac; it fre- 
quently shows in its interior irregular cellular spaces commu- 
nicating with each other, and has no internal epithelium, 
like the true encysted tumours. The fluid is precisely the 
same as that of serous dropsy, or of its varieties. Its 
essential constituent is fluid albumen which coagulates 
upon boiling, or exhibits the modification of this protein- 
compound which is not precipitated by boiling, but is 
readily thrown down by acids and alcohol. These mis- 
named hydatids are, therefore, only local oedema modified by 



240 



PATHOLOGICAL EPIGENESES. 



the histological condition of the affected part, and originate 
according to the same laws as oedema generally. They are 
observed rather frequently on many parts of the body, espe- 
cially on such as consist of a lax areolar tissue, as the sperma- 
tic cord (forming hydrocele of the cord), in the choroid 
plexus of the brain, also beneath serous membranes, i. e. 
between the membrane and the cellular tissue which connects 
it with the subjacent parts, beneath the pleura pulmonalis, 
under the peritoneum, and on the surface of the fallopian tubes ; 
also in the parenchyma of many organs, especially in that of 
the ovaries. A large proportion of the tumours known as 
ovarian dropsy belong to this group. These vesicles appear 
sometimes solitary, at other times in clusters ; this seems to 
be dependant partly upon the anatomico-histological structure 
of the organ, and partly upon the extent of the disease. 

I have repeatedly examined hydatids of the cord ; and they always 
exhibited the above mentioned character. That is, they consisted of lax 
areolar tissue distended into membranous vesicles containing, in irre- 
gular cellular spaces, a clear, transparent, aqueous fluid, which coagu- 
lates on boiling. When the fluid was evacuated by puncture, the 
areolar tissue collapsed and no trace of the previous cavities could be 
subsequently detected. The following case may serve as an example of 
a hydatid in which the fluid did not coagulate by heat. In 1837 while 
instituting an examination of the body of a deformed woman aged fifty- 
six years, who had been greatly afflicted with ventral hernia and ana- 
sarca, I found under the left kidney (which was healthy) between the 
peritoneum and lumbar muscles, a false hydatid of the size and shape 
of a human kidney. It was covered over by the peritoneum, and was 
attached to the lumbar muscles by lax areolar tissue : its sac consisted 
of a very delicate transparent membrane, which was formed merely of 
areolar tissue, possessed no internal epithelium, and was most inti- 
mately connected with the surrounding parts. It contained about two 
ounces of a homogenous, transparent straw-coloured fluid, in which no 
solid corpuscles could be detected by the microscope. This fluid was not 
affected by heat, but coagulated readily and abundantly on the addition 
of alcohol, nitric acid, and nitrate of silver ; it was, no doubt, the same 
which formed the oedema in the subcutaneous cellular tissue, and evi- 
dently was produced by the same cause. 



Another kind of these false hydatids closely corresponds 



ENCYSTED TUMOURS. 



241 



with the false dropsy, which was formerly described (p. 57). 
It originates in an obstruction of the excretory duct of a 
secreting part: the retained secretion accumulates and distends 
a certain portion of the duct or of the secreting organ itself 
into a tumour invested with an apparently closed sac, and 
containing an aqueous fluid, which, at first, chemically resem- 
bles the normal secretion, but may, subsequently, undergo 
changes by means of endosmosis and exosmosis. This kind 
of serous cyst is of less frequent occurrence than the preceding; 
it occurs in the kidneys, the fallopian tubes, the pancreas, and 
in the parenchyma of the lungs ; it may easily be confounded 
with the first kind, from which, indeed, it cannot always be 
distinguished with certainty, especially after the secretion 
has become changed. 

Through the kindness of my colleague Prof. Bergmann, I recently 
observed an undoubted instance of this kind in a kitten, about fourteen 
days old. The occluded uterus and the fallopian tubes were distended 
like a bladder, and upon the fimbria which were united by irregular 
adhesions, there were found several hydatid-like vesicles, the contents 
of which were clear and contained no albumen. 

With respect to the hydatid-like vesicles which are not unfre- 
quently observed upon the surface of the kidneys, it is often impos- 
sible to determine even by the most careful investigation, whether they 
belong to the variety under consideration, and are to be regarded as 
distended uriniferous tubes, or whether they should be comprehended 
in the first variety. Probably the ovula ndbothi should be classed here, 
and may be viewed as distended uterine glands. 

3. A third variety of serous cysts deserves the name of 
encysted tumours better than the two preceding. It consists 
of a perfectly closed cyst which externally is firmly connected 
with the surrounding parts, but internally exhibits a smooth 
surface resembling that of a serous membrane, and contains 
a clear serous fluid, devoid of regular corpuscular particles. 
The cyst itself consists of areolar tissue, and is soft and 
resembles a serous membrane, or firm, lardaceous or even 
apparently cartilaginous, according to the degree of development 
of the aforesaid tissue (see page 169). It varies in thickness 
in different cases, and its inner surface in general (in perfect 

VOL. I. R 



242 



PATHOLOGICAL EPIGENESES. 



forms probably always) becomes coated with a delicate epi- 
thelium, which essentially resembles that of normal serous 
membrane. In the perfect forms, moreover, the cyst con- 
tains vessels. The fluid in the interior closely corresponds 
with that of serous dropsy. I believe that this form of 
serous cysts arises in the following manner. As the first form 
owed its origin to serous dropsy, so does this to fibrinous 
dropsy ; in the first place there is formed a false hydatid 
(resembling our first form) whose walls are composed of 
expanded normal tissue. The dissolved fibrin gradually, 
however, becomes deposited upon the walls in the form of a 
closed saccular membrane, which usually consists of several 
layers ; the fluid thus deprived of its fibrin becomes identical 
with that of serous dropsy. The sac, at first amorphous and 
consisting of coagulated fibrin, becomes partially organised, 
is usually converted into areolar tissue, receives vessels, and 
becomes invested internally with an epithelium. The encysted 
tumour has now become permanent, and is not capable, like 
the first kind, of being entirely removed by absorption ; for if 
by the altered relations of endosmosis, the fluid originally 
effused, should become changed or decreased, nevertheless, 
on account of the internal epithelium, closure of the cavity by 
coalescence of its walls will not readily occur, and the cyst 
will maintain its independance, even through the changing 
relations of endosmosis, and the varying quantity of its fluid 
contents. These cysts can only be obliterated by means of 
adhesive inflammation ; an illustration of this mode of forma- 
tion of cysts from effused fibrinous fluids is afforded by a case 
described in the second part, in the chapter on the morbid 
anatomy of the brain, &c, where a cyst filled with fibrinous 
fluid had formed itself in the cerebral substance. The case 
figured and described in Plate v. fig. 5 and 6, also illustrates 
this mode of formation ; at the same time it serves to eluci- 
date the origin of a more complicated form of these serous 
cysts, which, up to the present time, has in general been 
erroneously included amongst the living hydatids. In this 



ENCYSTED TUMOURS. 



24 



form, a membranous cyst consisting of areolar tissue, con- 
nected with the surrounding parts, and furnished with an 
internal epithelium, encloses, but is unconnected with a 
second shut sac of a hyaline semi-transparent character, which 
generally admits of separation into many very thin layers, and 
consists of amorphous coagulated fibrin. It is filled as in the 
other cases with a serous fluid. The origin of this second 
sac, as evidently results from the description of Plate v. fig. 5 
and 6, must be explained in the following manner : from an 
already existing organised sac there takes place a new exu- 
dation of fibrinous fluid, which by means of the coagulation of 
its fibrin forms for itself a second membrane within the first. 
In the same way, it can be readily explained why such cysts 
sometimes contain altered blood, pus-corpuscles, granular 
cells, &c. For the means of discriminating these enclosed 
serous cysts from the living hydatids, we must refer to our 
chapter on the entozoa. 

Hence it appears that this form also of serous cysts 
is essentially nothing more than a variety of fibrinous 
dropsy, and is directly connected with the encysted dropsies. 
It occurs partly in serous cavities, as in the pleura, pericar- 
dium, and peritoneum, and partly in the parenchyma of 
organs, especially in those whose texture is soft, and admits 
of the easy formation of a cavity by the pressure of the 
effused fluid — -as the substance of the brain, the cellular 
tissue, &c. 

It is little to be wondered at if any one with Bichat and his followers, 
regards this form of serous cysts as newly formed serous membrane, 
since, like this, it certainly consists of areolar tissue with an internal 
epithelium ; nothing can, however, be gained by such a course ; 
on the contrary, this mode of considering it possesses the disadvantage 
that it might easily lead us to suppose the serous membrane first formed, 
and the fluid in the interior only secondarily secreted from it, whereas 
in fact, as we have already shown, the converse process of formation 
takes place. The enclosed serous cysts, whose mode of origin until 
now has been considered inexplicable, have usually been included in 
the entozoa under the name Acephalocysts. In general, the fluid of these 
cysts contains no corpuscular particles ; sometimes, however, there are 

R 2 



244 



PATHOLOGICAL EPIGENESES. 



observed in it fat-globules and minute corpuscles (elementary granules) ; 
in some rare cases it contains small organised formations, which are 
suggestive of the living hydatids presently to be described, and may 
raise a doubt with respect to the diagnosis of this form. For the parti- 
culars of the following case, I am indebted to the kindness of my friend 
Dr. Kohlrausch of Hanover. " In the clear aqueous fluid contained in 
cysts in the kidneys of a man, there swam an innumerable quantity of 
corpuscles which, although very different in size and appearance, were 
all connected by evident transitions. The smaller of these bodies were 
more or less regularly round, not smooth, but transparent. In their 
centre was observed a point which might be regarded either as a nucleus, 
or as an optical illusion. To this central point, which was of 
variable size, converged radial striae which gave to the whole corpuscle 
the appearance as if its capsule was plicated from the periphery to the 
centre. The diameter of these corpuscles varied from the 190th to the 
280th of a line ; smaller ones of the 370th, and larger to the 140th of a 
line were less frequent. There were also observed corpuscles which, 
possessing a rough coarsely granular surface and little transparency, 
appeared, at first sight, to be very different from those just described. 
Their diameter varied from the 112th to the 80th of a line. On 
properly arranging the focus there was seen, however, within the rough 
surface a smooth rounded outline which, when the enveloping layer was 
not thick or was partially absent, showed a double border. In many 
of these inner cells there were also seen the central point, and the 
striated radiations. The external layer was granular. On causing the 
corpuscles to rotate, it was seen that they were round. In addition to 
the above, there were observed larger and more opaque bodies, varying 
from the 50th to the 24th of a line, with a round granulated figure. 
Upon being treated for twenty-four hours with concentrated acetic acid, 
the corpuscles underwent no change ; nor were they affected within ten 
minutes by dilute hydrochloric acid. Upon boiling with ether they like- 
wise remained unaltered and no fat was extracted from them. They were 
insoluble in cold dilute nitric acid, but readily dissolved on the applica- 
tion of heat. This solution yielded on the addition of carbonate of potash 
a finely granular, amorphous precipitate. After evaporation of the 
nitric-acid solution, there remained a yellowish mass ; the purple-red 
reaction of uric acid could not be produced. In caustic potash the cor- 
puscles readily dissolved, in carbonate of potash less readily, but never- 
theless perfectly and without the development of gas." In conclusion I 
will add a few words concerning another possible mode of origin of 
serous cysts. It may be readily imagined, for instance, that elementary 
cells, whose general histological mode of formation was formerly consi- 
dered, might become so distended through the absorption of fluid as to 
form serous cysts. I am unacquainted with any case which seemed to 



ENCYSTED TUMOURS. 



245 



derive its origin in this manner ; indeed, all the elementary cells at 
present known, are far too small to permit of the supposition that even 
in their maximum degree of distention they could form cysts, which are 
always readily visible to the unaided eye. If, however, such a mode 
of origin is possible, it may be especially applied to the explanation 
of many of the so-named hydatids of the choroid plexus, since this part 
in the normal state already contains numerous large globular cells, 
which also perform a part in the concretions of this organ. This will be 
further discussed in the special part. 

The second division of the simple encysted tumours is 
distinguished from serous cysts by the circumstance that the 
contents do not consist of an aqueous fluid, but contain pecu- 
liar corpuscular particles which render them thick and pulpy. 
They sometimes resemble honey, sometimes boiled groats, and 
occasionally they have a gelatinous appearance. In accor- 
dance with these varieties in the contents, these tumours 
have received different names, and been termed hygroma, 
meliceris, atheroma, gummy tumour, &c. Such names are, 
however, in the highest degree, vague and unscientific. 

In this form the cyst is always perfectly closed, and firmly 
connected with the surrounding parts by adhesions of areolar 
tissue. It is organised, usually consisting of areolar tissue 
woven into a membrane, and containing vessels,* There 
usually may be distinguished upon its internal surface a 
decided epithelium consisting of cells,f which separates the 
contents from the membrane of the cyst. Thus far the mem- 
brane of these encysted tumours resembles that of true serous 
cysts ; but frequently it is more highly organised, so that 
whilst in serous cysts the membrane occupies a position 
parallel with serous membrane, it may in . these cases be 
compared to mucous membrane or the cutis. Sometimes, 
for instance, the internal surface of the cyst presents, upon 
certain spots, cauliflower excrescences — granulations which 
correspond more or less closely with the papillae of the skin 
or of mucous membrane ; indeed, in some cases, it contains 



* See Plate ix. fig. 3, 



f Plate ix. fig. 2. 



246 



PATHOLOGICAL EPIGENESES. 



glands which resemble the sebaceous and spiral follicles of the 
integument, as they have been represented by Kohlrausch.* 
In these cases the epithelium is more perfect than in serous 
cysts ; it resembles stratified pavement epithelium or thin 
epidermis, and consists of several layers of cells which, in 
complete analogy with the corresponding normal formations, 
show different stages of development. 

The contents of these tumours, as already stated, present 
many varieties which are explained with tolerable sufficiency 
by histological and chemical examination. We find in these 
encysted tumours : 

1 . Cells of different kinds, which usually lie loosely toge- 
ther : sometimes they are large, irregularly rounded or oval, 
mostly very much flattened, and, therefore, seen laterally, 
appear fibrous, either with or without a distinct nucleus, 
resembling the external layers of pavement epithelium and of 
epidermis ; sometimes they are small, with a distinct nucleus 
and nucleoli, perfectly analogous to the cells of the deeper 
(more recent) layers of epidermis and pavement epithelium ; and 
more rarely they are elongated, resembling cylinder epithelium.! 
There can exist no doubt concerning the origin of these cells ; 
they are epithelium rubbed from the sac. In this case as in 
the pavement epithelium and the epidermis, the outer layers 
are continually being thrown off whilst their under layers are 
being formed ; as the free epithelial cells cannot escape exter- 
nally, they accumulate in the sac; this they do the more 
readily as they rather strongly resist chemical influences, and 
being insoluble in the fluids of the body, cannot become 
resorbed. A gritty matter presenting a perfect resem- 
blance to the contents of these encysted tumours, some- 
times occurs as a morbid accumulation under the toe 
nails ; it forms a white, greasy, caseous mass, and like- 
wise consists of exfoliated, but retained epidermic scales. 
These cells are usually mixed with the other contents. 

* Miiller's Archiv. 1843, p. 365. f Plate ix. fig. 1, 2 and 4. 



ENCYSTED TUMOURS. 



247 



When the cyst resembles a serous membrane, and throws off 
little or no epithelium, these cells are comparatively rare, or 
appear to be altogether absent. In other instances, on the 
contrary, the cells prevail, and sometimes, indeed, form 
almost the whole contents. The last described encysted 
tumours have, generally, a thin surrounding membrane 
without secreting glands. 

2. Fatty matters of various kinds are almost invariably 
present in the contents of these tumours. They are partly the 
ordinary fats of the human body — olein and margarin, and oleic, 
margaric, and butyric acids ; partly cholesterin. They occur in 
the most varied proportions, and consequently, although 
encysted tumours can be arranged into well marked groups, 
they are not strictly separable from each other. Sometimes 
the fats predominate ; being either the common fats — olein 
and margarin — when the contents consist of irregular drops 
or masses, or when cells filled with fat, resembling the 
normal fat-cells are present : these form the transition from 
the encysted to the capsular fatty tumours, but are compara- 
tively rare; — or the contents consist for the most part of 
cholesterin, which occurs partly in the amorphous state, 
and partly in the form of distinct crystalline tables. # This 
variety of encysted tumour frequently presents, upon the 
interior of the cyst, several superimposed layers of cholesterin 
which glisten like mother of pearl ; it was, therefore, named 
the laminated nacreous fatty tumour by Cruveilhier, and 
cholesteatoma by Miiller.t 

These groups are, however, not strictly separated, since in 
different encysted tumours the individual fats are not merely 
mixed with each other, but also with the previously described 
cells in the most diversified proportions. 

The source of these fats, and the causes of their secretion 

* Plate ix. fig. 1 and 7. 

f See Miiller, op. cit. p. 50, or West's translation, p. 155, 



248 



PATHOLOGICAL EPIGENESES. 



cannot be shown with the same certainty as those of the cells. 
There can be no doubt that a part of the fat is secreted by 
the sebaceous follicles which Kohlrausch has demonstrated in 
the cyst, but such sebaceous glands cannot be discovered in 
all encysted tumours ; and the production of the cholesterin, 
which sometimes occurs in great abundance, and often forms 
almost the entire contents of an encysted tumour, cannot at 
present be sufficiently explained. 

3. Besides the substances which have been named, there 
are always various extractive matters, (water-extract, alcohol- 
extract, &c.) and salts, in the contents of encysted tumours. 
If the calcareous salts (phosphate and carbonate of lime) are 
deposited in considerable quantity, the cyst, as well as its 
contents, becomes entirely, or in part converted into a con- 
cretion, or, as it is usually expressed, the encysted tumour 
appears ossified. Such ossifications of encysted tumours 
rarely depend upon a new formation of true bony substance. 

The preceding observations are sufficient to afford a general view of 
the structure of encysted tumours and their contents. In addition to 
the cases in the description of the plates to which reference has been 
made, we may refer for examples of the individual forms to a case of 
meliceris described by Valentin,* and to the description of cholesteatoma 
by Miiller. Gluge's descriptions of the tumours belonging to this 
group, f are neither accurate nor come up to the present state of our 
knowledge ; he regards the crystals of cholesterin as horny exfoliations, 
and describes them as rectangular crystalline leaves, which is not the 
case. For chemical analyses, (with the exception of the older and less 
accurate), see those of Berzelius,J Valentin, myself§ and F. Simon. || 
The quantitative analyses naturally show no great correspondence, since 
in every separate case the quantity of the individual elements may be 

* Repertorium, vol. in. p. 307. 
f Untersuchungen, Part i. &c, &c. 

X Lehrbuch der Chemie, translated by Wohler, 4th Edition, vol. ix. 
p. 726. 

§ Anleitung z. Gebrauch d. Mikrosk. 1841, p. 460. 

|| Beitrage z. physiolog. u. patholog. Chemie, 1843, p. 436* 



ENCYSTED TUMOURS. 



249 



very different, as may be seen by a comparison of my analysis with that 
of Valentin. In 1000 parts there were contained : 



Water 
Fats 

Cholesterin 

Olein and oleate of soda 
Stearin (?) 
Fluid albumen and potash 
Chloride of sodium. 
Lime. 



Cellular substance (which 
Valentin regards as co- 
agulated albumen) 

Alcohol- extract with lactic 
acid 

Water- extract 



Valentin. 

887.15 



37.90 




59.23 



Myself. 

751 



38 



a trace 



92 

92 
27 



1000.00 1000 

Fee examined a ' lardaceous tumour' from the left hypochondrium of 
a venereal patient who had been treated with mercury ; it contained 87.5£ 
of cholesterin, and, therefore, was probably a cholesteatoma. This 
tumour enclosed in its inner layers much fluid mercury.* 

Dalrymplef has given a brief description of an ossified encysted tumour 
(i. e. one impregnated with calcareous salts). The encysted tumour 
was situated beneath the tarsal cartilage of the upper eyelid in a middle 
aged man ; instead of the usual caseous matter, it contained an earthy 
or osseous deposition. This tumour was rather larger than a pea and 
consisted of a hard earthy substance arranged into concentric layers, 
which under the microscope were seen to be entirely composed of firmly 
agglutinated epithelial cells ; instead, however, of forming transparent, 
thin scales with a central nucleus, they were thick and hard, and 
contained granular, earthy molecules which dissolved in dilute hydro- 
chloric acid. Between the cells there was no amorphous earthy deposit, 
but the whole consisted of epithelial cells which were opaque, of light 
brown colour, with a distinct large central nucleus. The deposition con- 
sisted, according to Gulliver, chiefly of phosphate of lime with a trace of car- 
bonate of lime. The above cited chemical analyses very distinctly show the 
gradual increase of the calcareous salts as ossification progresses. In my 

* Leop. Gmelin, Chemie, n. 2. p. 1373. 

f London Med. Gaz. June 1843 ; or Medico- chirurg. Transactions, 
1843, p. 238, with plates. 



250 



PATHOLOGICAL EPIGENESES. 



case the contents of the tumour contained only a trace of fixed salts ; in 
that of Valentin, on the contrary, more than .3% ; finally, Simon found in 
one of his cases 25.7-g- of fixed salts, namely 21.7-8- of phosphate of lime 
and 4.% of carbonate of lime, with a trace of iron and chloride of sodium. 
In Dalrymple's case the salts probably existed in still greater propor- 
tions. 

Similar encysted tumours occur in the inferior animals. I have 
observed one in the abdomen of a cat, between the skin and abdominal 
muscles. It contained about half an ounce of a brownish yellow, limpid, 
inodorous fluid, mixed with white flocculi. Its solid particles were 
shown by the microscope to be chiefly crystals of cholesterin ; besides 
these, masses of flattened, irregular, non- nucleated cells, completely 
analogous to those of the epidermis, and numerous brownish granules 
were observed. The cyst consisted of a stroma of areolar tissue, from 
the inner surface of which there sprung, in various spots, soft, cauli- 
flower excrescences, which resembled granulations or the irregular 
papillae of the cutis and mucous membrane : glands could not be detected 
in the cyst, even by the most careful examination. The inner surface 
was furnished with a fine epithelium consisting of delicate nucleated cells 
which perfectly corresponded with those of the Rete Malpighii. 

Although the most simple encysted tumours only enclose 
the elements which have been specified, others are occasionally 
observed, which likewise contain more highly organised 
tissues, as, for instance, hair, true bony substance, teeth, 
and horny structures. 

Of these substances hair appears most frequently in the 
contents of encysted tumours. It is found partly loose, uncon- 
nected with the walls of the tumour, agglomerated into irre- 
gular lumps, or scattered amongst the other elements ; and 
partly implanted and rooted in the cysts. This hair is usually 
light coloured, white, blond or reddish, more rarely brown 
or black ; sometimes it is short, a few lines in length, some- 
times long, and occasionally it extends to several feet, and is 
not inferior in length to the longest hair of a woman's head. 
In histological structure it perfectly resembles normal hair, 
exhibiting a medullary and cortical substance, having the 
usual squamous sheath upon its surface, and running to a 
point at the peripheral termination. Loose hairs commonly 
show a stunted bulb, like spontaneously detached normal 



ENCYSTED TUMOURS. 



251 



hairs ; those which are inrooted, on the other hand, possess 
a perfectly organised hair-root, a hair-sac presenting the 
normal structure, and likewise are frequently accompanied by 
sebaceous glands. The inrooted hairs are sometimes scat- 
tered over the entire sac, sometimes are collected in bunches 
upon certain spots of its surface, the rest of the sac presenting 
no hairs ; the latter is particularly the case with the longer 
hairs : the sac at the points where the hairs are affixed shows 
precisely the same structure as the normal cranial integu- 
ment. # The sac of these tumours, moreover, affords the 
same varieties as were described of the encysted tumours 
generally ; it is frequently of unequal thickness and exhibits 
patches of earthy depositions. The contents, besides the 
hairs, usually consist of fatty substances, which are chiefly 
olein, margarin, and fatty acids : cholesterin and epithelial 
cells are generally very scanty, or altogether absent. 

It admits of no doubt that all these hairs, like the normal 
hairs of the human body, originally developed themselves 
from hair-sacs, and were at first implanted in the cyst : the 
loose hairs have subsequently become detached and fallen out, 
and being insoluble, and therefore resisting absorption, have 
accumulated in the sac in precisely the same manner as 
was described of the epithelium in the interior of encysted 
tumours. It may happen that such detached hairs, at 
different points of their length (but not at their extre- 
mities), become again fastened to the sac by fibrinous 
exudation, calcareous depositions, cellular tissue, &c, 
(Cruveilhier) ; this, however, is only a mechanical, not 
an organic connection. The fat which forms the re- 
maining contents of these tumours is, without doubt, 
the product of secretion of the sebaceous glands which 

* A series of instructive plates and descriptions of encysted tumours 
containing hair are given by Cruveilhier, Anat. patholog. livr. xviii. 
Plates in. iv. v. 



252 



PATHOLOGICAL EPIGENESES. 



accompany the hairs, as Cruveilhier conjectured and Kohl- 
rausch has demonstrated. 

Many encysted tumours contain only hairs and fatty 
substances; others, however, present, in addition to these, 
portions of bone and teeth. These seldom lie free in the 
interior of the tumour ; but are most commonly between the 
layers of the cyst, or are enclosed in fibrous, semi-amorphous, 
knotty masses, so that these tumours are connected with the 
compound cystoids to be presently described. The bony 
portions consist of true osseous substance with osseous canals 
and bone-corpuscles (which are sometimes, however, more 
scanty than in normal bone) and are generally invested with a 
more or less perfect periosteum ; with respect to size, form, 
and number, they present, however, the utmost diversity. 
Attempts have been frequently made to compare them with 
bones of the normal or foetal body, and to explain them 
in this manner, but all such endeavours must necessarily 
foil. 

The teeth perfectly resemble normal teeth, sometimes those 
of the first, sometimes of the second dentition, and like them 
possess a crown and root, and consist of osseous substance, 
dentine, and enamel. Some resemble the incisors, others the 
canine, and molar teeth. Occasionally, however, they differ in 
form from normal teeth, being bent, or crooked ; and some- 
times two are blended together. These teeth are usually, but 
not invariably connected with the above mentioned pieces of 
bone, and are sunk into cavities in them, as into true alveoli. 
Sometimes we are enabled to observe the preceding stages of 
development of these teeth ; they appear enclosed in distinct 
teeth-sacs, show in their interior a tooth-germ, fragments of 
dentine, &c, and, in short, evince a progressive formation ; 
whence it follows that the development of these teeth in this 
unusual site, proceeds in entirely the same manner as that of 
the normal teeth (Kohlrausch). The number of these teeth is 
various, sometimes only a few are observed (as from one to 



ENCYSTED TUMOURS. 



253 



six) sometimes a larger number (to forty-four), indeed in one 
case, a single tumour of the ovary contained three hundred 
teeth !* 

Sometimes all the teeth are arrested at one stage of deve- 
lopment ; sometimes at very different stages, so that there are 
found co-existing in the same tumour, teeth which correspond 
to the first, and to the second dentition. In all the cases 
hitherto observed, encysted tumours, enclosing bone and teeth, 
have also contained hairs. 

In some more rare cases there is formed within encysted 
tumours a horny matter, which is connected with, or rather 
grows out of the sac. When such tumours are situated near 
the surface of the body they commonly break, and the horny 
substance grows out of the opening, and sometimes attains a 
considerable size. Home describes a case in which a horn 
arising in this manner acquired a length of 1 1 inches with 
a circumference of 2^ inches ; generally, however, they 
remain much smaller. Sometimes also they are thrown off 
and then reappear ; or they first form themselves when a 
common encysted tumour has become accidentally opened, 
and its sac thus exposed to external influences. These horns 
of varying form and size are usually curved like rams' horns, 
and sometimes spirally twisted : sometimes they are transpa- 
rent like true horny substance, sometimes rough upon their 
surface, and opaque : they are easily cut with a knife, and in 
their physical characters present the greatest similarity to the 
malformed hypertrophied nails, which are not unfrequently 
observed upon the toes. The same resemblance is maintained 
in their histological structure. I have closely examined several 
horns of this kind in our pathological collection. They con- 
sisted of a horny substance which could be easily cut into 
shavings. Under the microscope the substance appeared 
entirely indefinite, and almost amorphous, like the tissue of the 

* Cmveilhier, op. cit. livr. xviii. in which will be found plates and 
descriptions of this class of tumour. 



254 



PATHOLOGICAL EPIGENESES. 



nails, but upon digestion for a considerable time in caustic 
potash, the tissue separated into small scales, perfectly resem- 
bling those which are obtained by similar treatment from 
callous skin, corns, &c. 

The data which have been furnished preclude further doubt 
of the origin and signification of these horns: they are 
exuberant local growths of the epidermis of the sac, and 
bear the same relation to the cellular contents of the common 
encysted tumours, as the callous excrescences of the epidermis 
upon the surface of the body to the furfuraceous separation of 
the cuticle in pityriasis. 

Further particulars and descriptions of such horns may be found in 
E. Home, Philosoph. transact. 1791; J. F. Meckel, Handbuch der 
pathol. Anatomie, n. 2. p. 276 ; A. Cooper in A. Cooper's and Traver's 
Surgical Essays, p. 2, 1820, p. 233 et seq. with illustrations. These 
horns are similar in every respect to those which occur upon the external 
surface of the body, several of which have been described and figured by 
Cruveilhier, livr. xxiv. Plate ni. Encysted tumours with hairs are 
also found in the inferior animals ; in these cases the hair always 
resembles the normal hair of the animal : in sheep, encysted tumours 
contain wool; and in birds, tumours which enclosed feathers are found. 

Occurrence and further progress of the simple encysted 
tumours belonging to the second division. 

Simple encysted tumours containing fat and epithelial cells, 
occur in almost every part of the body, most frequently in the 
sub-cutaneous cellular tissue, particularly upon the cranium and 
the eyelids, but also in the face, upon the shoulders and the 
back; more rarely they exist in the internal organs and of these 
most frequently in the ovaries. They appear sometimes solitary, 
sometimes simultaneously upon many parts of the body; 
there have been observed, not unfrequently, four, five, six, 
and even nine upon one person. A. Cooper saw sixteen 
upon the head. They vary from the size of a pea to that of 
the fist, or even of a cocoa nut ; their diameter, however, seldom 
exceeds one or two inches. They occur at every age and in 
both sexes, and are sometimes congenital, although they 
usually arise later in life. In some cases they appear to be 



ENCYSTED TUMOURS, 



255 



hereditary, and not very unfrequently are observed in several 
members of the same family. 

The forms which contain hairs are most frequently situated 
in the neighbourhood of hairy parts, on the temples, near the 
eyebrows, &c. ; these which, besides hairs, also enclose 
teeth and bone, have been hitherto met with only in the 
ovaries ; those which contain horn, most frequently exist upon 
the upper part of the head. 

All these encysted tumours are perfectly non-malignant : 
although, like all non-malignant tumours, they may either from 
exciting causes, or, spontaneously, if they have attained a con- 
siderable size, become inflamed and break. Frequently, however, 
they exist throughout a whole life without injurious results. 
They can be removed without again forming : if, however, 
the extirpation has not been complete, and a part of the sac 
remains behind, this, on account of its epithelial investment, 
cannot become united to the adjacent parts : it continues to 
secrete, and the encysted tumour reappears in its former 
condition. 

Causes and origin. Some of the encysted tumours which 
enclose cells and fat, most probably arise from sebaceous 
glands of the skin, which, owing to some obstruction in their 
excretory duct, become distended with their accumulating 
secretion. This mode of origin is, however, certainly not so 
frequent as A. Cooper believed,^ and, at all events, can only 
apply to such as exist in or immediately beneath the skin : it 
cannot take place in encysted tumours of the internal parts, 
nor in those which contain hairs, bone, and teeth. Certainly 
in very many, if not in most instances, they are new organs 
formed by morbid processes, and we can readily suppose that 
their development is similar to that of serous cysts. If any 
pathological exudation, which is incapable of further organi- 
zation, as for instance pus, becomes deposited in the body, 



* Surgical Essays, vol. n. p. 236. 



256 



PATHOLOGICAL EPIGENESES. 



in such a manner, that it cannot escape, but irritates the 
surrounding parts, and gives rise to exudation, it becomes 
surrounded by a capsule of coagulated fibrin, which gradually 
organises itself in granulations, and at length is converted 
into a membrane resembling mucous membrane or cutis, and 
becomes furnished with an epithelium — a proceeding fre- 
quently observed in fistulae, &c. At first the original contents 
are still present ; they are, however, gradually resorbed, and 
give place to the secreted product of the newly formed sac- 
membrane, which always becomes further organised. In 
this way probably extravasations of blood, accumulations 
of pus, &c, which have no tendency to external rejection, 
may become the cause of encysted tumours. The origin of 
such tumours can frequently be attributed to external 
influences, contusions, &c, but more especially, continued 
pressure upon one spot : they may also arise, however, from 
constitutional, and internal causes acting in an insensible 
manner. The following example appears to me to contribute 
to the confirmation of this view of their mode of origin. A 
parrot in confinement died with a scrofulous deposit which 
had destroyed the skin by ulceration, and had caused caries of 
the cranial bones, &c. Upon dissection, the cavity of the 
abdomen appeared almost completely filled with a clear reddish 
fluid, which upon evacuation, spontaneously coagulated and 
characterized itself as fibrinous dropsy. In the neck were 
found after the removal of the skin two tumours of the size of 
walnuts, which from external appearance must have been 
regarded as glandular enlargements, but upon dissection 
presented peculiar characters. They both formed imperfect 
encysted tumours : their rather thick sac was formed of the 
substance of the hypertrophied distended gland, and upon its 
inner surface were numerous highly vascular granulations, 
covered with epithelium ; the contents formed a soft mass, 
which presented some irregular pus- corpuscles, but for the 
most part consisted of cells, perfectly similar to the epithelial 



ENCYSTED TUMOURS. 



257 



cells, and the cells in the contents of encysted tumours, and 
which, therefore, no doubt had become separated from the 
walls of the cyst. 

The encysted tumours which contain hairs, bone, and teeth, 
are also undoubtedly formed in a similar manner, and it is 
not necessary to assume, with Cruveilhier (op. cit.) and 
Bricheteau, # that these are the enclosed remains of a par- 
tially absorbed foetus. Nevertheless we are far from clearly 
understanding why, in these cases, there are developed in the 
sac-membrane such complicated formations as hair-sacs with 
hairs, sebaceous glands, bony substance, and tooth-sacs with 
teeth. 

The above opinion of A. Cooper, that superficial encysted tumours 
are occluded and distended sebaceous glands, is founded chiefly upon 
the observation frequently made by him, that by the introduction of a 
probe, the excretory duct can be again opened, and in this way the 
contents of the tumour may be evacuated without any special operation. 
Ph. von Walther,f with a view to weaken this theory even for the 
superficial encysted tumours, alleges that, notwithstanding frequent 
endeavours, he has never been able to perceive the sac-mouth, nor 
express any portion of the contents. The decision of this question is 
difficult, and in individual cases it is often impossible to say whether the 
encysted tumour has arisen in one or the other manner. The opinion 
of Cruveilhier and Bricheteau that encysted tumours which enclose hairs, 
teeth, and bones are the enclosed remains of a partially absorbed foetus, 
is liable to such weighty objections, that it must be totally abandoned. 
Cruveilhier himself admits that the tumours containing hair, which so 
frequently occur upon the scalp and eye-lids, and vary from the size of 
a pea to that of a walnut, are not in every case to be regarded as the 
remains of a foetus, or as an enclosed embryo ; the more so, as such 
tumours, in many instances, obviously originate after birth. Moreover, 
the perfectly analogous encysted tumours containing feathers, which 
are observed in birds, cannot be explained in this manner, since the egg 
is developed externally to the body. Nor is any such admission 
required to account for bony structures in the interior of encysted 
tumours, since a pathological formation of new osseous matter not unfre- 
quently takes place in other localities. Again, there exists no reason 

* Diction, des Sciences medic, t. xxvn. Kyste. 
f Grafe u. v. Walther, Journ. d. Chirurg. vol. iv. part nr. p. 384. 
VOL. I. £ 



258 



PATHOLOGICAL EPIGENESES. 



why, through the agency of local influences, the pathological formation 
of tooth-sacs and teeth in them, should be less readily effected than 
that of hairs, glands, and bones. In the inferior animals, teeth are 
not unfrequently observed in abnormal situations when intrafcetation is 
out of the question ; as for instance upon the temporal bone. Even 
admitting the possibility of the mode of origin assumed by Cruveilhier, 
its application to the cases in question, presents far greater difficulties 
than that of the other explanation. How does it happen, for instance, 
that every part of a foetus becomes completely resorbed with the 
exception of one solitary tooth, which remains perfectly unacted upon ? 
Cruveilhier himself has collected a number of cases where, in extra- 
uterine pregnancy a foetus was retained and became petrified by the 
deposition of calcareous salts,* but not one of the cases which he has 
described, presents the slightest resemblance to an encysted tumour 
containing bones and teeth. Moreover, how can it be accounted for 
that the teeth resemble not merely the milk-teeth, but frequently also 
those of the second dentition ? A foetus dead and undergoing absorp- 
tion for seven years is stated, in some unknown manner, to cast its 
milk-teeth and get a new set ! Also the number of the teeth sometimes 
met with, militates against this view : in one case, which Cruveilhier 
certainly terms doubtful (but upon what grounds ?) there were found in 
a single tumour three hundred teeth, a mass which we must suppose to 
be furnished by the accumulated remains of at least ten foetuses ! 

To the more simple encysted tumours which have been 
hitherto considered are allied 

b. More compound and less regular forms presenting tran- 
sitions between these and other kinds of tumours; to distinguish 
them from the simple, true encysted tumours (cysts), I shall, 
after J. Muller, call them cyst-like tumours (cystoids), pre- 
mising, however, that they no more form a strictly separated 
group than the other forms of tumour. They resolve them- 
selves into many sub-species or varieties which likewise cannot 
be strictly bounded, and result from combinations with other 
forms of tumour. As such varieties, we may distinguish : 

1. Foreign bodies which have penetrated into the organi- 
sation from without, as bullets, &c. also parasites, and entozoa ; 
and unorganised epigeneses formed in the organism, as calculi 
and concretions, which sometimes invest themselves with sacs 



* Anat. Patholog. livr. xvm. Plate vi. 



ENCYSTED TUMOURS. 



259 



and become encased as in a capsule. In this case the foreign 
body is the primary cause, and the sac a secondary structure 
which arises in this manner : the irritation of the foreign 
body causes an exudation whose fibrin organises itself, and 
usually passes into a vascular cellular tissue, which assumes a 
membranous form, and becomes furnished with an epithelium 
upon its internal surface. Somewhat similar phenomena ensue 
after extravasations of blood (apoplectic clots) : but in this 
case the sac-membrane is generally more or less blended with 
its contents. 

2. Compound cysts. It has been formerly stated that from 
the same cause several (true or false) independent serous 
cysts may be formed in the same vicinity. These formations 
are not to be regarded as compound, but as accumulations of 
simple cysts. It sometimes happens, however, as has been 
shown by Hodgkin, # that new, secondary cysts are formed 
out of the wall of the original cyst. These compound cyst- 
formations may present a double type ; for the secondary 
cysts develop themselves either : 

a. By the side of the primary cyst, chiefly towards its 
external surface, and there thus arise locular cystic structures 
whose separate cysts vary in form and size; or, 

b. The secondary cysts develop themselves on the interior 
of the wall of the parent-cyst in its cavity, and appear either 
pedunculated, or sessile with a broad base. They form clustered 
aggregations of cysts, which are filled with a serous or mucous 
fluid.f Such pedunculated or sessile growths from the wall 
into the interior of the cyst, do not, however, always form 
secondary cysts, but are often much more solid, and consist 
of various kinds of tissue. They are then to be considered as 
a more extended development of the above-mentioned granu- 
lations, which are frequently formed upon the inner surface 
of the wall of simple cysts. 

* Medico- chirurg. Transactions, vol. xv. p. 265, &c, with plates, 
f See Hodgkin, op. cit. fig. 1 — 6. 

s 2 



260 



PATHOLOGICAL EPIGENESES. 



3. Combinations of cysts with other forms of tumour. 
It not unfrequently happens that tumours which, in their 
histological structure, belong to the amorphous or orga- 
nized fibrous tumour, to enchondroma, &c, contain in their 
interior cavities of various kinds, which are furnished with 
more or less smooth walls, and enclose a serous, mucous, 
fatty, or gelatinous fluid. These are the combined cysts and 
cystoids : on account of their fleshy stroma, J. Miiller # com- 
prehends them under the common name of Cystosarcoma. 
He distinguishes three separate forms of them : 

a. Cystosarcoma simplex, in which the cysts, enclosed in a 
fibrous sarcoma, have each their distinct membrane, the 
inner wall of which is simple, smooth, or at most beset with 
a few vascular nodules. This form may be described as the 
cystic formation combined with the simple cyst. 

b. Cystosarcoma proliferum, in which the cysts enclosed 
in the sarcomatous mass, contain younger cysts in their inte- 
rior, which are attached to their walls by pedicles ; — cystic 
structure combined with compound cysts. 

c. Cystosarcoma phyllodes, in which the cysts, included 
in a sarcomatous substance, are ill-defined, form several cavi- 
ties and chambers without a distinct proper membrane, and 
are filled more or less completely with solid, foliaceous, cauli- 
flower growths from the floor and walls of the cavity. This 
form corresponds with the cystic formations where solid granu- 
lations spring exuberantly from the walls of the cyst. 

The forms already described may serve to afford an idea of the 
complicated relations of the compound and combined cyst-formations. 
The subject is as yet very insufficiently worked out, and there still 
exists great obscurity concerning it, especially with respect to the 
relations and causes of their development. Although, perhaps, in 
individual cases the origin may be sufficiently explained, general laws 
of formation cannot, at present, be laid down. The most important 

* J. Miiller iiber den feineren Ban der Geschwiilste, p. 56, or West's 
translation, p. 170. 



MALIGNANT TUMOURS. 



261 



literature is to be found in the works referred to in the text, by Hodgkin 
and J. Miiller : descriptions and illustrations of some forms are given by 
Gluge in his Atlas d. Patholog. Anatomie, Part iv. under Cyst-forma- 
tions ; also by Andral in his Patholog. Anatomie. Hodgkin includes 
malignant tumours amongst the compound cyst-formations ; a view 
which will be presently criticised. 

MALIGNANT HETEROLOGOUS TUMOURS. 

Pseudoplasmata. 

The nature of non-malignant tumours consists essentially 
in this, that they are formed of the persistent elements of the 
body, and as such maintain their existence and participate in the 
general metamorphosis of the tissues. They may indeed be 
destroyed by softening and ulceration, but this is effected 
through the agency of causes which are not inherent in their 
nature, but are only accidental and exoteric. 

Malignant tumours, on the other hand, proceed of neces- 
sity to softening from esoteric causes ; the softening being a 
necessary consequence of their development.^ 

This circumstance sufficiently distinguishes the two classes 
of tumours. But other pathological formations also soften 
without being, on this account, malignant. Thus, for 
instance, softening takes place in all suppurations in which 
the pus is developed from a solid cytoblastema. In this case, 
however, the morbid epigenesis alone softens, the original 
tissues taking no part in it ; if the pus is evacuated externally 
or becomes resorbed, they return to their original condition, 
and re-assume their previous functions; the affected part, 
with the exception of some trivial changes which occasionally 
remain, is restored in integrum. The case is far different 
with malignant tumours. In these the softening is not con- 
fined to the morbid epigenesis amongst the original histolo- 

* It certainly happens that tumours, which at their commencement we 
should regard as malignant, occasionally do not soften, but this is depen- 
dant on accidental or external causes, much like those which induce 
softening in non- malignant tumours. 



262 



PATHOLOGICAL EPIGENESES. 



gical elements, but the latter become themselves involved in 
the process of softening, and are also destroyed, so that 
the expulsion of the mass from its place of formation is 
attended with a loss of substance. The softening of the 
pseudoplasmata, therefore, is not innoxious, but malignant and 
ulcerative ; it consists not in a healthy suppuration, but in a 
process of ulceration. 

The difference between non-malignant and malignant 
softening is not confined to the above points ; it extends even 
to the morphological formation of the product of the soften- 
ing. In the non-malignant softening this consists of the 
normal pus-corpuscles formerly described ; in the malignant, 
on the other hand, of very irregular molecules, which show 
scarcely a trace of organization, and resemble the products of 
the putrefaction of organic bodies, mixed with fragments 
of the destroyed tissues. 

This statement perfectly corresponds with that which was 
formerly advanced as the distinction between non-malignant 
and malignant suppuration. In fact no strict line of demar- 
cation can be interposed between malignant or ulcerative 
suppuration (ulceration) and the malignant tumours; some 
kinds of the latter — the typhous, the scrophulous, and some 
of the tubercular depositions — form a debateable territory, 
which may be as justly annexed to the former as to the latter. 
This, however, holds good only for some forms ; others, as 
encephaloid and scirrhus, are histologically distinct from 
common ulceration. The view maintained by C. Wenzel, # 
that pseudoplasmata (carcinoma) and ulceration are identical, 
is therefore, with certain restrictions, perfectly correct: it 
does not, however, hold good in all cases, and may be more 
accurately expressed by stating that the two are connected by 
a neutral ground. 

Besides the morphological distinction between ulcerations 

* Ueber die Induration und das Geschwiir in indurirten Theilen, 
Mainz, 1815. 



MALIGNANT TUMOURS. 



263 



and pseudoplasmata, there is another which has relation to 
the extent of the malignancy. In ulcerations the malignancy 
is usually local, the destruction of the tissues, and the entire 
pathological process continuing, for the most part, topically 
circumscribed. In the pseudoplasmata, on the contrary, the 
epigenesis, and with it the destructive process is frequently 
propagated from the spot originally affected to other parts, 
and this propagation and extension attain such a degree 
that the death of the patient ensues. These different degrees 
of malignancy can he discriminated as local, and as general. 
Upon further consideration it will be perceived, however, that 
even this distinction is untenable. There are ulcerations 
which do not remain locally circumscribed, but spread exten- 
sively and attack different and often widely separated parts of 
the body, and finally, by an exalted influence upon the whole 
organism, induce death ; in these, therefore, we perceive not 
merely a local but a general malignancy. On the other side, 
there exist tumours absolutely corresponding in all other 
points with the malignant, but in which the destruction is 
merely local, and the loss of substance even becomes repaired 
without its exerting an influence upon the organism suffi- 
ciently exalted to occasion death. This is observed to be fre- 
quently the case with tubercles, and sometimes with scirrhus. 
For although some surgeons maintain that every scirrhus 
after its removal by operation again returns, other experienced 
practitioners, amongst them Travers, # maintain the contrary ; 
and it can be no longer doubted that pulmonary tubercles 
may heal without recurring. Hence in this point of view 
ulcerations and malignant tumours are not strictly separated. 

After this preliminary consideration of the relations in 
which the pseudoplasmata stand to the other pathological 
epigeneses, we shall proceed to examine more attentively 
those points which the different pseudoplasmata possess in 
common. 

* Medico-chirurg. Transactions, vol. xv. p. 219. 



264 



PATHOLOGICAL EPIGENESES. 



These tumours do not arise, as was formerly supposed, 
from a transmutation of the normal tissues ; they are, rather, 
new formations which penetrate amongst the previously exist- 
ing histological elements of the body. Their cytoblastema is 
always originally fluid and only subsequently becomes solid : 
it generally fills up the interstices of the tissues amongst 
which it is deposited, as completely as mortar the spaces 
between the stones of a wall. This may be directly observed 
in pulmonary tubercle and in scirrhus, and it results from 
these observations that the cystoblastema is secreted in a fluid 
state, even in the cases where we find it solid : for this perfect 
impletion of all, even of the smallest spaces between the 
elements of the tissues can only be effected by a fluid. 

The cytoblastema is undoubtedly derived from the vessels, 
and is probably effused through the agency of the same causes 
which give rise to fibrinous dropsy. 

We possess no accurate knowledge respecting the chemical 
composition of the cytoblastema: although all observations 
hitherto made, tend to show that it contains the same elements 
as fibrinous dropsy, and that its coagulability depends upon 
dissolved fibrin. It may be possible that the cytoblastema of 
the different pseudoplasmata contains specific chemical princi- 
ples — peculiar modifications of the protein-compounds : the 
present state of animal chemistry does not, however, allow of 
a positive affirmation or denial of this question. 

The effused cytoblastema undergoes changes which are 
very dissimilar in different pseudoplasmata : in some forms it 
becomes organized, and is converted into cells, amongst 
which, in certain cases, fibres and blood-vessels are formed : in 
others, scarcely a trace of organization can be detected, the 
cytoblastema remaining amorphous, or showing only very feeble 
indications of cellular structure. 

In all cases, however, the new formation finally softens, 
and becomes disintegrated, and in the disintegration there 
are involved not merely the permanently amorphous, but also 
the organised parts. The product of the softening is not, 



MALIGNANT TUMOURS. 



265 



as in normal pus, an emulsion of organised corpuscles, but a 
fluid with irregular broken up organic molecules, — an organic 
detritus, which, only in the highly organised pseudoplasmata, 
contains a few integral or broken cells. 

The softened pseudoplasmata are thus also morphologi- 
cally distinguished in an essential point from normal pus, and 
correspond more nearly with the unhealthy pus of ulceration. 
The fluid resulting from the softening of the pseudoplas- 
mata, is not bland and innocuous, on the contrary, it is usually 
ichorous, corrodes the surrounding parts, and has a putrid 
odour. Upon what substances these injurious properties 
depend, has not been chemically determined, but the fact 
itself is undoubted. 

The period which elapses between the deposition of the 
cytoblastema and the softening is various in different cases* 
but is always longer than that which is requisite to develop 
normal pus from a cytoblastema ; here, again, the softening of 
the pseudoplasmata coincides with ulceration. 

As in suppuration, so also in the pseudoplasmata, the 
softening is not confined to the newly formed products ; the 
normal tissues amongst which the cytoblastema was deposited 
are also involved in the destruction, and simultaneously 
soften. 

These facts enable us to explain in a sufficient manner the 
local malignancy of the pseudoplasmata. It is determined by 
entirely the same causes which we formerly recognized as 
conditions of ulceration. There exist, however, two causes 
of which, no doubt, either may be efficient, or both may 
co-operate. In the first place, from the long incarceration of 
the coagulated cytoblastema the tissues become injuriously 
compressed, and since they are in some measure isolated, their 
nutrition is impaired and their death thus occasioned. 
Secondly, the corrosive property of ichor, which frequently 
resembles a putrid fluid, exerts its action upon them, and 
likewise contributes to their death. 

Allowing that these causes account for the local malignancy 



266 



PATHOLOGICAL EPIGENESES. 



of the pseudoplasmata, we have still to seek for an explana- 
tion of their extension, and of their pernicious influence upon 
the whole organism. 

It has been mentioned that these consequences do not 
always ensue, that for instance, tubercles sometimes continue 
local, and the destruction caused by them may, as in other 
instances where loss of substance has occurred, heal by cica- 
trization. This, however, is not usually the case ; in general, 
the pseudoplasmata progressively extend until they terminate 
in death. As the non-malignant tumours grow by the con- 
version (conformably to the law of analogous formation) of 
the nutritive fluid secreted in their surrounding parts into a 
structure resembling themselves, also so may malignant 
tumours be propagated according to the same law. Since, in 
this manner, the increased extent of the tumour is accompanied 
by an extension of the softening, the loss of substance and the 
destruction are constantly increasing. 

The softening of malignant tumours usually commences 
not upon their surface, but in their interior ; the product of 
the softening, therefore, not being immediately discharged, 
the ichorous pus continues for some time in contact with the 
walls of the vessels, and, by endosmosis, its fluid parts are 
taken up into the lymph and blood; exerting a morbific 
influence, in a manner at present but little understood, 
upon these fluids, and thus gradually inducing a general 
cachexia. Moreover, the vessels which intersect the tumour 
become involved in the process of destruction, some indeed, 
becoming obliterated by it, whilst others are opened, and into 
the gaping mouths of such veins and lymphatics, not only 
the fluid but the solid particles of the softened mass enter, 
and proceeding further into them, excite phlebitis and inflam- 
mation of the lymphatics, with their consequences. 

These evil effects of their increase and of their general 
morbific influence upon the collective organism are shared by 
the pseudoplasmata and by ichorous suppurations ; the former, 
however, commonly possess them in a higher degree, being 



MALIGNANT TUMOURS. 



267 



mostly deeper seated, and, therefore, retaining the ichor for a 
longer period, and moreover increasing with greater energy. 
These consequences may be obviated by the removal of the 
pseudoplasma by operation previous to its softening, and 
upon this rests the advantage to be derived from the employ- 
ment of the knife in the malignant epigeneses. In order to 
be useful, such an operation must be radical, i. e, no part of 
the pseudoplasma should be left behind. 

But the general malignancy of the pseudoplasmata is not 
confined to this ; there commonly arise also on other spots of 
the body in the vicinity of the original pseudoplasma, or distant 
from it, simultaneously with the first or subsequently, other 
pseudoplasmata of the same kind. Upon what this depends 
we know not, and pathological anatomy has thrown no more 
light upon this point, than respecting the* causes which give 
rise to pseudoplasmata generally. 

That the pseudoplasmata are not produced by metamorphosis of the 
normal tissues, but that like all other pathological formations, they 
take their origin from an amorphous cytoblastema, is indubitable : obser- 
vations which establish this will be adduced in our observations on the 
individual pseudoplasmata. It is no less indisputable that this cyto- 
blastema is furnished from the vascular system, especially from the 
capillaries. It is possible that the cytoblastemata of the pseudoplas- 
mata from their earliest stages differ from those of the other patholo- 
gical epigeneses. I have had repeated opportunities of examining such 
cytoblastemata, but have never been able to detect any peculiarity in 
them. Our knowledge of the different modifications of the pro- 
tein-compounds is, however, still very imperfect, and we possess no 
means of recognising mere microscopic quantities. This question 
must, therefore, for the present remain unanswered. Our knowledge 
is not more definite regarding the causes which lead to the formation 
of the pseudoplasmata. The present state of this subject may be 
thus briefly summed up : firstly, it may be assumed that the formative 
cause consists in a depraved condition of the fluids, i.e. certain elements 
of the blood become changed, or there occur in it new and peculiar sub- 
stances which after their deposition in the parenchyma of organs, 
necessarily become converted into pseudoplasmata. According to this 
view, therefore, there already exists in the blood, previous to the for- 
mation of any pseudoplasma, a cancerous or tubercular matter whose 
deposition upon a definite spot may determine the localization of the 



268 



PATHOLOGICAL EPIGENESES. 



disease, or its propagation to several organs may result from the first 
deposition not removing the whole of this matter from the blood. 
Through the continual production of this matter, and its deposition in 
various parts of the body, the disease becomes constitutional. Against 
such a view, which attempts to explain the disease solely on the princi- 
ples of humeral pathology, there may be urged weighty objections. In 
the first place such specific morbid principles have not as yet been 
demonstrated; indeed, the failure of every attempt to trace them, 
renders their existence very improbable, and if, nevertheless, in 
modern times, certain physicians speak of such matters, (stating 
for instance, that tubercles consist of casein), this only shows the 
deficiency of their knowledge of organic chemistry. Moreover, it 
cannot be conceived why such a principle circulating in the blood 
throughout the system, becomes deposited only in certain spots, and 
does not, with the nutritive fluid, exude every where from the capillary 
vessels ; and consequently, why pseudoplasmata do not arise simulta- 
neously in every part of the body. We are, then, compelled to assume 
that certain parts of the body possess a peculiar attractive power for 
these principles, something similar, we must suppose, to that by which 
the parenchyma of the kidneys especially separates urea: for this 
separation cannot be ascribed to peculiarities of the vascular system, 
since pseudoplasmata may arise in nearly every part of the body. 
This could not be an original, innate, attractive force, because for the 
reason last mentioned, all parts of the body would then possess it, and 
thus the local occurrence of pseudoplasmata would remain unexplained. 
It must be first acquired by a change in the constituents of the body, 
which may be either direct or mediately transferred from the nervous 
centres. With this admission, however, the morbific cause becomes, 
partly at least, transferred from the province of humoral pathology to 
that of nervous pathology, or solidism. 

A second view, which is closely allied to the first, seeks the cause of 
the pseudoplasma in a contagium animatum: for instance, it ascribes to the 
specific cells of cancer the power, like that of the spores of cryptogamic 
plants, of propagating the disease by the expulsion of new cells or by 
the genesis of such cells in their interior. Two distinct modifications of 
this view may be exhibited. According to one, all pseudoplasmata 
in every case spring from such a germ : according to the other, this is 
but one of the modes of propagation, and is especially adapted to ex- 
plain the formation of new pseudoplasmata in an organism already 
infected. There are very weighty objections to both opinions, which I 
shall state at length in speaking of cancer, where this view can be 
supported with greater plausibility than for the other pseudoplasmata. 
It may in this place be provisionally remarked, that by the assumption of 
a contagium animatum, neither the origin of the pseudoplasmata, nor 



MALIGNANT TUMOURS. 



269 



even their propagation in an organism already infected, is sufficiently- 
explained. The other theories which have heen advanced are still less 
tenable. I deem it, therefore, right that we should candidly avow our 
ignorance of any thing certain, respecting the general formative causes 
of the pseudoplasmata. In the consideration of the individual forms we 
shall frequently revert to this subject. 

The malignant epigeneses are as little capable of precise clas- 
sification as the non-malignant tumours. They may, how- 
ever, according to the higher or lower degree of organisation 
which they attain before their disintegration, be reduced into 
certain groups, but these are still less strictly separable than 
in the case of the non-malignant formations; transitions 
between the individual forms are of common occurrence, and 
indeed, the same tumour not unfrequently shows totally dis- 
similar elements; the reduction of these formations into 
numerous species with a multiplicity of names is, therefore, 
quite unjustifiable. We discriminate, firstly, pseudoplasmata 
which are slightly or not at all organised ; and secondly, such 
as attain a higher grade of organization. As representatives 
of the former class may be pointed out the depositions in 
typhus, and in scrophulous tumours ; of the second, encepha- 
loid and scirrhus. Many varieties of tubercle form a connect- 
ing link between these leading divisions. 

In the classification of the pseudoplasmata there has hitherto pre- 
vailed and still, to some extent, prevails a very great confusion. In 
fact, there is scarcely a part of medicine where more obscurity and pre- 
judice prevail than here. In the following pages I shall consider the 
pseudoplasmata mainly in a histological point of view : the question 
whether the commonly received distinctions between the morbid pro- 
cesses, which generally accompany the different pseudoplasmata are 
positively established, does not properly belong to our subject ; it will, 
however, be borne in mind, although we shall not permit it to carry us 
too far from our especial subject. 



270 



PATHOLOGICAL EPIGENESES. 



FIRST CLASS. 

PSEUDOPLASMATA SLIGHTLY OR NOT AT ALL ORGANIZED. 

The tumours belonging to this class are characterized by 
the circumstance, that during the whole process of their 
development, from their first appearance to their softening, 
they show a very low degree of organization. The mass 
forming them appears either entirely indeterminate and 
amorpho-granular, or it attains, in the most highly developed 
cases, to a very imperfect cellular structure : the product of 
their softening is an indeterminate granular detritus. 

Morphologically, as well as pathologically, (that is to say in 
relation to the concomitant local morbid phenomena), these 
new formations are most closely allied to ulceration, from 
which indeed they cannot be strictly separated. In general, 
however, they do not remain local, but appear simultaneously 
on several parts of the body. But this propagation does not, 
as in the more highly organised pseudoplasmata, depend 
upon the conversion (in conformity with the law of analogous 
formation) of the nutritive fluid in their vicinity into a mass 
resembling them, but is rather due to the same cause which 
gave rise to the first pseudoplasma becoming repeated ^in its 
vicinity or in a distant part of the body. The cavities and 
ulcers produced by the softening of these depositions can, 
therefore, spontaneously heal with much greater facility, than 
those which ensue from the softening of the more highly 
organised pseudoplasmata. 

From the second class — the more highly organised pseudo- 
plasmata — they are histologically distinct, although even here 
transition forms are not wanting. 

They appear absolutely non-vascular, and if vessels are 
found in them, these are not of recent development, but 
belong to the normal tissues, amongst which the epigenesis 
was deposited. 



TYPHUS DEPOSITS. 



271 



Their common termination is the softening of the deposited 
mass. The period which elapses between the deposition and 
softening is very different in individual cases ; it may vary 
from a few days or weeks to several months. In general the 
softening extends to the enclosed normal tissues, and the 
united product opens for itself a passage, and is discharged 
externally. An ulcer is thus formed : this either spreads by 
continuance of the original process (new deposition with 
softening) in the surrounding parts, until it terminates in 
death ; or the ulcer heals by cicatrization, whilst the loss of 
substance is repaired by permanently organised epigeneses. 

In other cases the softened mass does not become discharged 
but is gradually resorbed, and the loss of substance is 
repaired by a similar cicatrization to that which occurs in 
the preceding case. Sometimes the reparation is interrupted 
by the deposition, instead of softening, becoming converted 
into an earthy or cretaceous mass, and thus forming a con- 
cretion. 

The separate forms of these epigeneses have generally been 
distinguished less by histological and anatomical characters 
than according to the true or pretended peculiarities of the 
morbid processes with which they are usually associated. I 
shall follow this classification as it has the most special rela- 
tion to practical medicine. 

DEPOSITIONS IN TYPHUS. 

In the majority of the cases of typhus, pathological epige- 
neses occur in different parts of the body, most frequently in 
the intestinal canal between the mucous membrane and the 
muscular coat, in Peyer's glands, (especially at the termination of 
the small intestines) and in the mesenteric glands: less frequently 
in the spleen and lungs, and in and under the mucous mem- 
brane of the trachea. These formations usually appear as 
a more or less firm lardaceous mass of a yellowish or whitish 
colour, which is deposited in greater or less abundance, 



272 



PATHOLOGICAL EPIGENESES. 



amongst the normal tissues, gradually softens, and as the 
normal elements of the region become also involved in this 
process, forms ulcers which either heal by cicatrization, or 
continue until the death of the patient. In many cases death 
takes place before the commencement of softening. Of the 
phenomena which attend the softening and cicatrization in 
the different organs we shall treat in the special part : in 
this place our attention will be directed to the mass alone. 

This must, in every case, be deposited in the fluid state, 
and subsequently assume the solid form by coagulation : 
otherwise it could not so completely fill up all the interstices 
of the tissues. Upon examination, however, it is invariably 
found coagulated : at least, I am acquainted with no instance 
where it has been observed still fluid. 

Under the microscope the following constituents are recog- 
nized in the mass. 

1. An amorphous, semi-transparent stroma. 

2. Molecular granules from a size too minute to estimate, 
to the 800th of a line in diameter ; sometimes interspersed 
with larger fat globules. 

3. Larger corpuscles (imperfect cells and cytoblasts) from 
the 800th to the 300th of a line in diameter, rarely larger. 
Some of these enclose smaller corpuscles (elementary granules 
and nucleoli) which are wanting in others.* 

By acetic acid the amorphous substance is rendered more 
transparent, and at length invisible ; the granules as well as * 
the cytoblasts and nucleoli remaining unchanged, whilst the 
cells become paler and gradually disappear. By alkalies, on 
the contrary, the entire mass is rendered diaphanous, and 
there remain visible only a greater or smaller number of 
granules : this reaction is produced more rapidly by potash, 
than by ammonia. 

These three elements, in different cases, are present in very 
varying quantities, the amorphous matter seldom predomi- 



* See Plate vi. fig. 12, 13, 14, 15. 



TYPHOUS DEPOSITS. 



273 



nates ; most commonly the granules are in excess, and in this 
case the mass has, in refracted light, a grayish brown appear- 
ance. The cells and cytoblasts are sometimes so thinly 
scattered that they are with difficulty perceived; in other 
cases they are more frequent, but it is very seldom that they 
are the predominating element. When softening takes place, 
the amorphous matter disappears ; the granules, however, and 
the cells and cytoblasts appear suspended in a fluid, as in an 
emulsion. The softened mass frequently contains unsoftened 
particles of considerable size which, by the solution of the 
surrounding parts, become isolated, and are thus discharged 
as agglomerate masses. 

The softening of typhous matter usually proceeds rapidly, 
following the deposition in the course of a week or 
only a few days ; it is but seldom that several weeks inter- 
vene. The typhous matter cannot be histologically dis- 
tinguished from the deposits which occur in scrofulosis and 
tuberculosis : distinctions may, indeed, be sometimes perceived 
between these different deposits but these are not greater 
than are observable between the varieties of typhous matter. 
Neither can it be distinguished with precision from many 
forms of inflammatory exudation in the early stages of 
development, nor from the product of many malignant sup- 
purations, from exudations in gangrenous parts, and similar 
processes, whilst its differences from normal pus, and from 
the more highly organized pseudoplasmata are very obvious. 

The question of the origin and signification of this typhous matter 
can be only partially answered by pathological anatomy. It appears 
to be ascertained that this matter is secreted in a fluid state from 
the capillary vessels. Moreover, the cause of this separation is, doubtless, 
a local hyperemia of these vessels ; as, indeed, in typhus may be 
readily proved by direct observation. The secreted matter is, therefore, 
a part of the blood which, shortly after its separation, coagulates. But 
we are acquainted with only one principle in the human body, which is 
capable of spontaneous coagulation, namely, fibrin. Of this, therefore, 
the typhous matter chiefly consists : it is, however, as in all similar cases 
pervaded by the other elements of the blood. The question here sug- 
gests itself : Is this fibrin normal or has it, whilst still in the blood, 
VOL. I. T 



274 



PATHOLOGICAL EPIGENESES. 



undergone a specific change ? The possibility of such a change cannot 
be denied, since we know that fibrin is very transmutable : but the 
assumption of such a change without a demonstration of its nature by 
organic chemistry, is of no advantage in a scientific point of view. By 
such a hypothetical transmutation of the fibrin, we may endeavour to 
explain why the typhous exudation is not converted into normal pus, but 
breaks up without any distinct organization. This view, however, may be 
opposed by another equally plausible : it is very probable that in typhus 
the normal properties of the tissues are deprived of their ordinary energy , 
and that their formative power is impaired. In this diminished energy 
of the original tissues may, likewise, be sought the reason why the exuda- 
tion does not become organized, but undergoes disintegration. Probably, 
however, neither the one nor the other view alone is correct, and doubt- 
less there are a multiplicity of concurrent causes in action, whose mani- 
fold intricacies cannot be at present unravelled. With this brief view 
of the subject, I wish to express myself as opposed to the opinion, that 
there exists in the blood a specific typhous matter, with the deposition 
of which, in certain parts of the body, the disease localizes itself and 
terminates. At the same time the local importance of this deposit 
cannot be questioned. A great number of cases of typhus proceed to a 
fatal termination from the effects of these depositions, from ulceration, 
perforation of the intestine, &c. 

With respect to the histological arrangement of typhous matter, it 
remains to be observed that foreign ingredients are frequently inter- 
mingled with it — as epithelial cells, chyle-corpuscles, &c, which must 
not be confounded with the histological elements of the matter itself. 

SCROFULOUS DEPOSITS. 

In scrofulosis, as in typhus, depositions occur in various 
parts of the body — most commonly in the lymphatic glands and 
their vicinity, but also in other glands, and other organs. 
In an anatomical and histological point of view, the scrofulous 
matter bears so great a resemblance to the typhous, that here 
we shall only notice their distinguishing characters. 

The essential difference is, that here the whole proceeding 
is accomplished much more slowly — the deposit and the soften- 
ing generally lasting as many weeks, or even months, as in 
the other case days. 

The matter also exhibits in different cases great anatomical 
variations ; it is sometimes dense and firm, so that thin sec- 



SCROFULOUS DEPOSITS. 



275 



tions can be made ; sometimes it is lardaceous, sometimes 
soft and crumbling like new curds. It is likewise sometimes 
colourless and semi-transparent, sometimes whitish, some- 
times of a yellow tint. Histologically, it is perfectly similar to 
typhous matter, and consists essentially of the same elements : 
it presents an amorphous stroma, molecular granules, and 
undefined cells and cytoblasts, varying in diameter from the 
600th to the 300th of a line, occurring in very different pro- 
portions and mixed with fat-globules. The granules are 
partly protein-compounds, partly fat, and in part calcareous 
salts : the latter disappear with effervescence on the addition 
of nitric acid. 

After its softening, the matter consists of the same indeter- 
minate granular ' detritus' as the typhoid deposit. Softening 
and ulceration do not, however, always ensue : in many cases 
the above mentioned calcareous deposition becomes predomi- 
nant, and the mass is converted into a concretion. 

Scrofulous matter cannot be with certainty distinguished 
histologically from typhoid or tubercular matter. There 
occurs every intermediate grade between it and ordinary 
suppuration. 

Hie statements formerly made respecting the mode of origin and 
the signification of typhous matter hold good equally here. Further 
observations concerning the conditions of the lymphatic glands infil- 
trated by scrofulous matter, follow in the special part. The reader 
will find a histological and chemical investigation of these tumours by 
Valentin in his ' Repertorium,' vol. n. p. 282. 

TUBERCLE.* 

Tubercles form the most frequent and therefore the most 
important of this class of deposits. They have especially 

* The literature of tubercle is remarkably copious ; in addition to the 
various works on pathological anatomy and pathology generally, we may 
mention ; Laennec, de l'Auscultation mediate ; Carswell's Pathological 
Anat. Tubercle, fasc. 1, 1833; Schroder van der Kolk, Observationes 
anat.-patholog. fasc. 1, 1826 ; Clark, on Consumption ; Sebastian, de 

T 2 



276 



PATHOLOGICAL EPIGENESES. 



attracted the attention of physicians, and for this reason merit 
an attentive consideration. 

Originally the name ' tubercle' was a very general one ; 
in accordance with its proper signification, it expressed all 
nodular tumours, and even at the commencement of the pre- 
sent century, Baillie applied the term to fibrous tumours 
of the uterus. At the present day, however, its meaning 
is much more limited, and by tubercles we now under- 
stand those pathological epigeneses which are engendered 
in consequence of a specific disease or morbid tendency — 
tuberculosis. 

In establishing this definition, however, sufficient care has 
not been taken to point out, firstly, that all tumours which 
are regarded as effects of tuberculosis, invariably show 
the same anatomical and histological constitution, and can 
be distinguished with certainty from all other pathological 
epigeneses ; secondly, that, on the other hand, the appear- 
ance and course of tumours which, from their anatomical 
structure, must be regarded as tubercles, are always attended 

origine, incremento et exitu phthiseos pulmon. obs. anat. Groningse, 
1837; Louis, Reeherches sur la phthisie, 2nd edition, Paris, 1843; 
or Walsh's translation, London, 1844 ; Boudet, recherches sur la 
guerison naturelle ou spontanee de la phthisie pulmonaire, Paris, 1843 ; 
Zehetmayer, iiber die Lungentuberculose, Zeitschrift der Gesellschaft 
der Aerzte in Wien, Jahrg. 1, No. ri. ; Engel, die Tuberculose, ditto, 
1, 1844, No. v. 

Further references are given in the special department. A very per- 
fect view of the literature of the subject is given by Cerutti, Collectanea 
qusedam de phthisi pulmon. tuberculosa, Lipsise, 1839, 4. 

For information on the histology of tubercle we may especially 
refer to: Gerber, Handbuch der allgemeine Anatomie, 1840, p. 187^ 
&c, or Gulliver's English edition, p. 305, &c. ; Gluge, Unter- 
suchungen, No. n., p. 182, &c. ; Klencke, Untersuchungen und Erfahr- 
ungen, vol. n. p. 12, &c. ; Lebert in Muller's Archiv. 1844, p. 190, 
and in his Physiologie pathologique, 1845, vol. i. p. 351, &c. ; 
Giinburg, die Pathologische Gewebelehre, 1845, vol. i. p. 100, &c. ; 
Addison in the Transactions of the Provincial Medical and Surgical 
Association, vol. ii. 1843, p. 287, &c. 



TUBERCLE. 



277 



with the morbid phenomena which are pointed out as charac- 
teristic of tuberculosis ; and thirdly, that tuberculosis is posi- 
tively always the cause and not merely the effect of local 
tubercles ; on the contrary, it was conceived that enough had 
been done when this correspondence was rendered probable 
for only one organ — the lungs, where they certainly appear 
most frequently. It is, however, certain that physicians fre- 
quently regard tumours in the brain, under the peritoneum, 
and even in the lungs to be tubercles, when their histological 
structure shows that this is not the case ; moreover, as was 
stated generally of the pseudoplasmata belonging to this class, 
true tubercular matter cannot be distinguished with certainty 
from other epigeneses, namely from the scrofulous and 
typhous, and from many other ulcerative processes. In a 
pathologico-anatomical view, therefore, the definition of 
tubercle is by no means strictly limited ; whether or not this 
is the case with the morbid process which is named tubercu- 
losis cannot in this place be investigated, # 

I will now endeavour to consider the general relations of 
this pathological epigenesis : its peculiar relations in individual 
organs will be considered in the special part. 

With respect to the origin of tubercle, there can be no 
doubt that its formative substance is secreted from the 
capillary vessels in a fluid form, in perfectly the same manner 
as was stated of typhoid matter. It afterwards fills up all 
the interstices of the tissues in a manner too perfect to be 
accomplished by any substance that was not originally fluid. 
Probably this secretion results from the same causes as that 
of fibrinous dropsy generally, and is preceded by a local hyper- 
emia of the participating capillaries, Whether or not this 
proceeding should be termed inflammation, is a question 
which will be subsequently considered. Pathological anatomy 
fails to demonstrate an especial cause for this secretion from 



* See Engel, op. cit. 



278 



PATHOLOGICAL EPIGENESES. 



the blood into the parenchyma, in the formation of tubercle. 
Whether or not this secreted fluid contains other elements 
than in the normal state, and whether there exists ready 
formed in the blood a specific tubercular matter which, 
on this occasion, becomes separated, can be answered with as 
little certainty for this, as for the typhous and scrofulous 
depositions. Hitherto all attempts to demonstrate such a 
specific principle in the blood have failed : this speaks certainly 
against its existence, although we cannot deny that with our 
present means, we are unable to demonstrate every modifica- 
tion of the protein-compounds, and this would be the point 
to be considered. 

This fluid condition of the tubercular matter cannot be 
directly observed. Some, indeed, assert that they have seen 
it, but the difficulties of satisfying ourselves of the presence 
of a specific cytoblastema of this kind, differing from the 
normal nutritive fluid are so great, that the correctness of 
such observations may reasonably be called in question. 
Whenever tubercles are observed in what may be presumed to 
be their earliest stages, they appear solid, form a more or less 
dense mass, and fill up all the interstices of the elementary 
tissues in which they are deposited. The tissues are usually 
neither displaced nor altered by the tubercular matter ; on the 
contrary, they in general retain their normal position ; they 
are, however, as closely and perfectly invested by it, as the 
stones of a wall by the solidified mortar which has been 
applied between them. We can most readily convince our- 
selves of this condition by treating fine sections of tubercular 
deposit from the lung with acetic acid or caustic ammonia. 
By means of these reagents the opaque tubercular matter is 
rendered transparent, and under the microscope, the enclosed 
portions of lung (the intersecting fibres) are perceived to be 
arranged amongst the tubercular matter just as in the normal 
state. This experiment, however, does not always succeed, 
for sometimes the tubercular matter contains numerous 
molecular granules which are not rendered transparent by 



TUBERCLE. 



279 



these reagents ; in this case the preparation, even after the 
above treatment, remains opaque or at least turbid. 

On microscopical examination, tubercular matter is found 
to be composed of different elements, whose proportions 
are extremely various in separate cases, but which essentially 
correspond with the elements of the typhoid and scrofulous 
matters formerly described. There are : — 

Firstly, a transparent, amorphous, vitreous stroma, occur- 
ring in large masses, which perfectly resembles coagulated 
fibrin and micro-chemically reacts like it : that is to say, 
acetic acid and alkalies render it pale, and finally cause its 
disappearance ; # 

Secondly, minute granules (molecular granules) varying from 
the 800th of a line in diameter to inappreciable minuteness, 
chiefly of a roundish form, and occurring in large masses of a 
brownish colour. These granules do not always exhibit the 
same chemical reactions ; they seem, therefore, to be diffe- 
rently constituted. Some of them appear modified protein- 
compounds, such as we have formerly had occasion to notice : 
they are insoluble in acids and alkalies, and in ether, and are 
little or not at all attacked by other reagents. Others consist 
of fat, and dissolve in boiling ether. Amongst them we 
frequently notice larger fat-globules presenting the same chemical 
character. Finally, a third kind of these granules are calca- 
reous salts (phosphate and carbonate of lime) : they dissolve 
in acids with partial effervescence.f 

Thirdly, imperfectly developed cells and cytoblasts, with 
or without nucleoli : the former are partly soluble in acetic 
acid ; the latter are insoluble : both disappear on the addition 
of caustic ammonia or potash. The cells are generally very 

* This substance does not admit of expressive delineation; it is 
intended to be shown in Plate vi. fig. 1. a. b. ; fig. 2, a. ; fig. 3, a. ; 
fig. 5, b. a. 

f These granules are most obvious in softened tubercles, being set 
free by the solution of the amorphous stroma enclosing them. See 
Plate vi. fig. 6. 



280 



PATHOLOGICAL EPIGENESES. 



imperfectly developed, and a distinct nucleus can seldom be 
recognized. Their size usually varies between the 400th and 
the 300th of a line, their diameter rarely attaining to the 
200th of a line.^ With these more or less fully developed 
cell-formations in tubercular matter, we must not confound 
other structures, presently (p. 283) to be described, which 
are frequently found in the vicinity of tubercle. 

These three elements occur in individual cases in very 
different proportions. The amorphous stroma seldom pre- 
dominates ; the granules more frequently — sometimes, indeed, 
almost the entire mass of tubercle appearing to consist of 
them ; of these, the protein-granules are generally pre- 
dominant ; the fatty granules are less frequently in excess ; 
and there are cases in which the calcareous granules 
prevail. The cellular formations are sometimes entirely 
absent, so that it is often impossible to discover even 
traces of them in tubercular matter : in other cases 
almost the whole mass of the tubercle appears to consist of 
cells and cytoblasts. The degree of organization of the tuber- 
cle depends on the prevalence or deficiency of these cell- 
structures. 

The naked eye is itself sufficient to reveal differences in 
different cases of tubercle. As the extremes of these diffe- 
rences, we may notice two which have been characterized as 
distinct varieties of tubercle. In one variety the tubercular 
matter is of a gray or whitish colour, semi-transparent and 
homogeneous : this has been named gray infiltration. In 
the second variety the matter is yellowish, opaque, dense, 
lardaceous or mellow, like some sorts of cheese {yellow tuber- 
cular matter). Between the two varieties, however, there is 
presented every gradation. These two varieties present his- 
tological differences ; in the former we have an amorphous 
mass and cellular structures ; in the second, the granular 
elements prevail. The absence of these granules is a suffi- 

* See Plate vi. fig. 1 ; fig. 3, a, b; fig. 4, a; fig. 5, a. 



TUBERCLE. 



281 



cient explanation of the greater transparency, the grayish 
white colour, and smooth section of the former ; while their 
occurrence accounts for the opacity, yellow colour, and 
irregular, granular section of the second variety. These 
varieties of tubercular matter have been regarded as the same 
substance in different stages of development, and in many 
cases this view is undoubtedly well-founded ; thus gray tuber- 
cle in the process of its development, as it approaches to 
softening, usually assumes a granular appearance, and may 
be converted into the yellow variety. But on the other hand 
we also meet with tubercles of the yellow variety in appa- 
rently the very earliest stages of development. Hence there 
can be no doubt that this variety can exist primarily, since, 
from the very commencement, granules are separated from 
this tubercular mass as from gray tubercle. 

Further changes of tubercular matter : softening. Of the 
above constituents of tubercular matter, the amorphous sub- 
stance is present from the commencement, as soon as the 
tubercle becomes firm : it is, without doubt, the product of 
the coagulation of fibrin ; moreover, the greater part of the 
granules are frequently present from the first. The imper- 
fect cells and the cytoblasts make their appearance gradually ; 
their development is the only trace of the process of organi- 
zation of which tubercle is capable. Other organized struc- 
tures such as we have learned to recognize as products of 
formative activity, and such as occur in the more highly 
organized pseudoplasmata, are here absent. In tubercle 
there are formed neither fibres nor vessels, and in fact, even 
the normal vessels of the part in which the deposition occurs, 
become compressed, emptied, and impervious ; none but a 
few of the larger vessels with thick walls remaining uninjured 
Hence, if, in examining tubercle, vessels capable of being 
injected are found in it, they must not be regarded as epige- 
neses, but merely as the remains of the original vessels. 

The ordinary course of tubercular matter is to soften, and 
this occurs in the following manner. In the first place the amor- 



282 



PATHOLOGICAL EPIGENESES. 



phous stroma liquefies ; the elementary granules then separate 
and the cells and cytoblasts become liberated, in part break up, 
and form a sort of emulsion either with a pre-existing or a 
newly secreted fluid. In this process of softening most of the 
tissues, between which the tubercular matter has been depo- 
sited, take a share ; they also break up, the more delicate 
first, the firmer resisting the destructive action for a longer 
period, and the product of their disintegration mixes with the 
softened tubercle, presenting the appearance of a thick, quasi- 
purulent fluid, which therefore forms an organic detritus 
saturated with fluid (serum), and under the microscope ex- 
hibiting very indefinite characters. It appears as an aggre- 
gation of elementary granules with cytoblasts and cells in 
various states of preservation. # Sometimes crystals of cho- 
lesterin or of ammonia co-magnesian phosphate, or certain 
organized structures originating from the textures surround- 
ing the tubercle are present. In the fluid of the softened 
tubercle we usually find a viscid (pyin-like) substance which 
coagulates on the addition of acetic acid. The softened mass 
usually exhibits a tendency to external rejection, in this point 
of view resembling the pus of an abscess. In some few cases 
it becomes gradually resorbed, disappears, and the cavity 
formed by the destruction of the tissues is filled by the 
formation of a cicatrix, or else a portion of the tubercular 
matter remains as a compact and sometimes even as a 
quasi-cartilaginous mass, or undergoes a species of fatty dege- 
neration. 

In other cases the development of the tubercular matter 
proceeds in a different manner. A copious deposition of 
calcareous granules occurs in the tubercular matter, and con- 
tinues to increase, while the other constituents are removed by 
resorption. In this manner tubercle becomes converted into 
a white pulverulent, or chalky mass, or else into a dense stony 
substance. This modification of tubercle is usually surrounded by 



* See Plate vi. fig. 6. 



TUBERCLE. 



283 



a kind of cicatrix formed of thickened fibrous tissue, and may 
remain for years in the organism without undergoing further 
change, or becoming incrusted on its surface. We shall 
return to this subject in our remarks on concretions. 

Its relation to the surrounding parts. — Tubercular 
deposits form either nodules of very varying size, or 
are continuously distributed through a whole organ, or 
its greater part. We consequently make a distinction 
between tubercular nodules and tubercular infiltration; when 
the former are very minute, not exceeding a millet-seed in 
size, but yet visible to the naked eye, we name them 
miliary tubercles. These two forms of tubercular deposit 
are not separated by any definite limit; there are, how- 
ever, the following distinctions whose establishment fre- 
quently varies in accordance with the subjective opinion of the 
observer. Neither form of deposit has got a well-defined 
limit, each usually extending almost imperceptibly into the 
surrounding healthy tissues, unless in certain cases arrested by 
some peculiar anatomical arrangement, as in the case of glands. 
Sometimes, however, a secondary limitation of tubercular 
deposition is brought about by other pathological epigeneses 
appearing in the surrounding parts ; this may arise either 
from the influence of the surrounding tissues on its me- 
tamorphosis, being stronger at the margin where the amount 
of deposit is small, than in the centre, and, in this way, 
other products being formed at the periphery of the mass ; 
or from the deposited tubercle exciting irritation in the 
surrounding parts, and thus giving rise to a cytoblastema 
distinct from that of tubercle, and becoming converted 
into pus and granular cells. Hence at the margin we 
frequently find histological elements distinct from those in 
the centre of tubercle — namely pus-corpuscles and gra- 
nular cells ; we may also expect to see epithelial cells, and 
other elements of the original normal tissues, which on 
making a microscopic examination, must not be confounded 



284 



PATHOLOGICAL EPIGENESES, 



with the elements of tubercle. After the process of 
softening these elements mix with the liquefied tubercular 
mass, and thus increase the number of the constituents of 
the detritus deposited by it. 

Whether the cytoblastema of these peripheral formations 
is identical with, or distinct from that of the tubercular 
matter itself, this much is certain, that the latter can exert 
no great influence on it, and that its generative power is 
very small. This is an essential difference between tubercu- 
lar matter and the more highly organized pseudo-plasmata. 
We shall see that they possess this capacity in a high degree, 
and that the cytoblastema separated in their neighbourhood, is 
excited to analogous development ; while in tubercles this is 
not the case, or at most only occurs occasionally to a slight 
degree. The extension of the tubercular deposit is dependant 
only on the unknown cause which, in the first instance gave 
rise to it (the tuberculous diathesis). 

For this reason tubercles frequently heal without any 
artificial aid, when this tendency, and, at the same time, the 
occurrence of the deposition- terminate. The cure is effected, 
either by the cavity becoming filled by the formation of a 
cicatrix, by its being invested by newly formed membrane 
(mucous membrane with epithelium), by the tubercular mass 
becoming resorbed, or finally by its becoming converted into 
a concretion by the deposition of calcareous salts. The 
details of these processes are different in the various organs, 
and we shall enter with more minuteness into the subject in 
the special part, in the chapter on the morbid anatomy of 
the lungs. 

This deposition occurs most frequently in the lungs and 
the lymphatic glands, but likewise in the kidneys, liver, 
spleen, mucous membranes, external skin, bones, and almost 
every part of the body. 

The period intervening between deposition and softening, 



TUBERCLE. 



285 



varies extremely in different cases; in some it does not 
exceed a week or two, whilst it may extend to many 
months. 

The diagnosis of tubercle is sufficiently explained by the 
preceding observations. To determine the presence of tuber- 
cle with accuracy, the microscope is generally requisite, and 
with the aid of that instrument, it may be distinguished with 
certainty from most other pathological epigeneses. It is dif- 
ficult, indeed frequently, quite impossible to distinguish it 
from typhous and scrofulous matter, and from certain forms 
of unhealthy suppuration. In the softened condition, it is 
much more difficult to recognize than in the unsoftened state, 
since, as we have already mentioned, other elements are then 
mixed with it. 

Respecting the chemical composition of tubercle, nothing 
is at present definitely known. 

Such statements as those of Preuss,* in which he asserts that tubercle 
consists in part of casein, are founded on investigations which do not 
at all correspond with the present state of our chemical knowledge, and 
any one expressing his belief at the present time, that tubercles consist 
of casein, would show that his ideas of zoo-chemistry were extremely lax 
and unsatisfactory. At present all that we can say is, that tubercular 
matter consists principally of a protein- compound, as has been shown 
by Lehmann,f and has been repeatedly confirmed by myself. There 
can, however, be no doubt that during the progress of softening, the 
tubercles undergo chemical changes ; Lehmann has shown that 
during this process the phosphorus and sulphur in the protein- 
compounds diminish, and that ultimately they altogether disappear. 
SchererJ has submitted to ultimate analysis the tubercular matter from 
various organs. The very interesting results which he has obtained, 
appear to show that tubercle in different cases, presents a different com- 
position, and is not always identical with protein. We must, however, 
be cautious in drawing general conclusions from such isolated analyses, 
valuable though they be, for as it is hardly possible to obtain tubercle 
perfectly free from enclosed tissue, or other foreign admixtures, elemen- 

* Tuberculorum pulmonis crudorum anal, chemica, Berol. 1835. 
t Physiologische Chemie, vol. i. p. 197. 

t Untersuchungen zur Pathologie, p. 212, &c., or Simon's Animal 
Chemistry, vol. n. p. 478, &c. 



286 



PATHOLOGICAL EPIGENESES. 



tary analyses do not in this case give such certain results, as in cases 
where the substance to be analysed can be exhibited in a state of chemical 
purity. In addition to the protein-compounds, there naturally also 
exist fat, extractive matters, a substance resembling pyin, and various 
salts, as constituents of tubercle. When the tubercles become converted 
into concretions, the calcareous salts predominate over the organic con- 
stituents ; thus in cretaceous tubercles of this nature, Thenard found 
only 3£ of organic matter, and 96£ of salts. Lebert's* opinion that 
cretaceous tubercles consist chiefly of chloride of sodium, and sulphate 
of soda, and that the salts of lime are present only to a small amount is 
incorrect. The analysis of Boudet on which he founds his opinion, does 
not bear on the question, for a tubercle containing in 1000 parts only 
0.697 of inorganic matter is not calcareous, and other analyses of tuber- 
cles actually calcareous, show that the salts of lime occur to a very large 
amount. Most calcareous tubercles, although only slightly soluble in 
water, dissolve almost entirely on the addition of an acid. There is, 
moreover, a chemical impossibility in Lebert's opinion : salts which 
dissolve as readily in all the fluids of the body as these soda-salts, 
cannot exist in the body in a solid form, and produce concretions which 
remain exposed to the action of those fluids for months and even years : 
they would dissolve and be carried away in a few hours, or at any rate 
in a day or two. The preceding view of the structure of tubercle is 
based on hundreds of original observations made during a series of years, 
and coincides in all its principal points with the statements of most 
unbiassed observers, as for instance, with the valuable Memoir of Lebert 
in Muller's Archiv, which unquestionably contains the best histological 
account of tubercle yet published. We shall only notice a few of the 
numerous opinions that have been promulgated on this subject. Gerberf 
whose opinion on the formation of tubercle in general corresponds with 
mine, draws a distinction between albuminous and fibrinous tubercle, 
regarding the former as unorganized, the latter as organizable. A dis- 
tinction of this nature is certainly possible theoretically, but can be of no 
practical value, since the capability that tubercles possess s for organiza- 
tion is very small, and no definite limit can be drawn between those 
that possess it to a greater or lesser degree. This bears on the long 
controverted point, whether tubercle is or is not organizable : it is 
unnecessary, however, to say any thing further on this point. But 
that unorganizable tubercle consists of albumen, and organized tubercle 
of fibrin is a hypothesis whose admissibility I might be inclined to ques- 
tion. Gerber further distinguishes the organizable fibrinous tubercles, 

* Muller's Archiv. 1844, p. 289. 

t General Anatomy of Man and the Mammalia, English edition, 
p 305. 



TUBERCLE. 



287 



according to the degree of their organization, into hyaline tubercle, cyto- 
blast tubercle, cell tubercle, cellulo-fibrous tubercle, and filamentous 
tubercle. These distinctions are not altogether unfounded, but they 
have relation to the deposition rather as it occurs in the domestic ani- 
mals than in man. Addison* regards tubercles as a deposition and 
accumulation of abnormal epithelial cells, and the evil consequences of 
this deposition in the lungs and other internal organs are dependant 
according to him, on the epithelial cells not being removed (as occurs 
on normal free surfaces,) but remaining and exerting an injurious effect 
on the surrounding parts. These abnormal epithelial cells consist, 
according to Addison, of colourless blood- corpuscles which stagnate in 
the pulmonary capillaries, and afterwards become converted into these 
cells. Addison regards many tissues, for instance, epithelial cells and 
pus-corpuscles, as formed from the colourless blood-corpuscles. Here 
then there is an elementary view of the structure of morbid tissues dif- 
fering essentially from mine. As, however, it is shown in numerous 
parts of this work, that these structures are formed from an amorphous 
cytoblastema, a special refutation of Addison's views appears unneces- 
sary. A few other points belonging to this subject may be elucidated by 
a statement of the views which have been laid down by J. Engel, in his 
very interesting essay on tuberculosis. f Engel distinguishes between 
interstitial tubercle (miliary tubercle) and infiltrated tubercle. The for- 
mer is the result of a peculiar condition of the blood, closely approxi- 
mating to its state in typhus ; the latter is in all cases an inflam- 
matory product. The conversion of the inflammatory exudation into 
tubercular matter, and not into other structures, depends, according to 
Engel, on various conditions : — in the first place on the exudation 
itself, under which head we may consider : a. Too large a quantity of 
the coagulated fibrinous exudation, by which the complete infiltration 
of the whole mass with moisture is prevented, b. Deficiency of the 
fluid of organization generally, and, in this way, too great a dryness of 
the exudation, c. Foreign admixtures, namely blood-corpuscles, d. Pre- 
existing tubercular matter, acting in accordance with the law of analo- 
gous formation already laid down. A second series of conditions depends 
on the part affected, and the whole organism. Under this head we may 
arrange : a. The activity of the metamorphosis of tissue — in proportion to 
the inertness of the metamorphosis, is the tendency to the formation of 
tubercle, b. And what is essentially the same thing, contiguity with 
vascular organs — the greater this is, so much the less is the tendency to 
tuberculization ; and c, The condition of the vital powers — in proportion 

* Transactions of the Provincial Medical and Surgical Association, 
vol. ii. p. 287, &c. 

t Zeitschrift d. Gesellsch. d. Aerzte in Wien, .Tahrg. 1, p. 353. 



288 



PATHOLOGICAL EPIGENESES. 



to their weakness, the facility for tubercular deposition is increased. 
There is a third series of exoteric conditions, amongst which we must 
mention pressure, and very likely cold. 

Engel likewise attempts to elucidate the further changes of tubercle 
and their consequences. As soon as the tubercular deposit has assumed 
the solid condition, it begins to act on the tissues, and to destroy them. 
It afterwards softens, aud this softening is, according to Engel, a kind 
of putrefactive process depending on a chemical alteration in the 
exuded fibrin. Sometimes, however, this softening does not proceed 
from a primary decomposition of the tubercular matter itself, but is 
induced by exoteric influences, as for instance, by imbibition of the deposit 
with water from adjacent cedematous parts, or by inflammatory products 
deposited in the vicinity of the tubercle. The softened tubercular mat- 
ter reacts on the blood, in which it (or at least the fluid portion taken 
up by resorption) may induce modifications. The softened tubercular 
matter may also be converted into an ichorous fluid, if there is a suffi- 
cient quantity of it, (for minute depositions do not undergo this change), 
if there is a due amount of moisture, if it is far removed from highly 
vascular organs and there is consequently little metamorphosis of tissue, 
if the vital powers of the organism are depressed, if it is in contact with 
extraneous matter, as atmospheric air, fragments of food, bile, faeces, 
urine, &c, and finally, if there is an undue excess of warmth. Other 
changes may accompany, or may occur in place of the above alteration ; 
thus a portion may liquefy and be resorbed ; the conditions for this 
change are, that there shall not be too large a mass of exudation, that 
it shall be in a position to be freely infiltrated with fluid, and that the 
age of the patient shall be advanced. When the amount of water con- 
tained in tubercle is reduced by absorption to a minimum, the tuber- 
cular matter shrinks and becomes indurated. The conditions for this 
change are a densely compressed mass of exudation, and generally 
speaking, advanced age. In all essential points, this is the same as 
what is meant by the tubercles becoming obsolete. These changes relate 
to the still unsoftened tubercle. The changes occurring after softening 
are : a, cicatrization, the conditions of which are that there must not be 
too great a destruction of tissue, that there should be a healthy condi- 
tion of the surrounding parts and no induration, and that the age of 
the patient be not very far advanced, b. Entire or partial resorption, 
which occurs the more readily in proportion as the deposit is small, 
and the surrounding parenchyma healthy, c. The admixture of the 
softened tubercle with pus, &c. ; and d, the conversion of tubercle into 
atheroma or calcareous concretions. All these terminations of tubercle 
are usually associated with the curative process. In order, however, 
that a perfect cure may ensue, it is necessary, that the fresh formation 
of tubercular matter should cease, and on this point, Engel gives it as 



TUBERCLE. 



289 



his opinion, that in a certain condition of the blood, these depositions 
do not occur. I have entered thus fully into Engel' s views, because I 
regard his attempt to explain the formation of tubercle as very important 
and praiseworthy. 

In the leading points I agree with Engel, and if there is much in his 
Essay that is not very strictly denned, as for instance, the term " in- 
flammation," which without further explanation, he puts down as the 
cause of infiltrated tubercle, and if also his views regarding the pecu- 
liar condition of the blood are not based, as they ought to be, on accu- 
rate chemical analysis, still he appears to have adopted the only true 
mode by which we can hope to arrive at accurate conclusions regarding 
the nature of tuberculosis and similar processes. The formation of tuber- 
cle by a contagium animatum — by semi-individual cells as Klencke* 
supposes — appears to me perfectly untenable, and I do not consider that 
we have sufficient evidence of the accuracy of his inoculation-experi- 
ments. Moreover, how can tubercles, not consisting of cells, propagate 
in this way ? I shall, in a subsequent page, return to the consideration 
of this point. Another opinion has also been put forward, namely, 
that tubercles consist of hydatids ; this is based on the observation that 
occasionally quasi- tubercular deposits are found in encysted tumours 
(as we have already seen), and in hydatids and the cysts of certain 
entozoa (as will be shown in a future page). These facts show, at all 
events, that from the above-mentioned structures a quasi- tubercular mass 
can be produced, but they do not conversely show that tubercles must 
always arise from these structures. 

Respecting the causes of softening I entirely agree with Engel in 
thinking that they may be referred partly to influences residing within 
the tubercular mass, and partly to external influences, as extreme mois- 
ture, suppuration of the surrounding tissues, &c. The investigation 
of the conditions in individual cases, which alone can be serviceable to 
practical medicine, must remain to be undertaken by our successors. 

SECOND CLASS. 

EPIGENESES OF A MORE HIGHLY ORGANIZED CHARACTER f 

The forms of tumour belonging to this class are extremely 

* Untersuehungen und Erfahrungen, vol. i. p. 121. 

f The literature of this class of tumours is very abundant. We may 
especially notice the chapters devoted to the subject in the treatises of 
J. F. Meckel, Andral, and Lobstein, on Pathological Anatomy. Their 
appearances as presented to the naked eye, are to be seen in Carswell's 
VOL. I. U 



290 



PATHOLOGICAL EPIGENESES. 



various, and exhibit in their anatomical and histological rela- 
tions, in their progress, and in their duration, very great 
differences ; and hence we find that many members of this 
group have received distinct names. But in these tumours 
it is just as impossible as in the non-malignant, to have 
genera and species such as we have in descriptive zoology and 
botany. Such a fine distinction and separation of species, 
based on unimportant points, would from the very first 
lead to each individual tumour being regarded as a distinct 
species, and we should thus have millions of names. I shall, 
therefore, endeavour to group and consider these forms in 
accordance with their essential common points, and shall only 
describe the most prominent ones as peculiar varieties. As 
familiar illustrations of this class we may notice the terms, 
cancer and carcinoma, which in the following pages must 
always be regarded as synonymous. 

Carcinomatous structures are distinguished from the pre- 
ceding class — the slightly organized epigeneses — by a higher 
degree of organization ; they not only show a more highly 
developed cellular structure, but frequently also fibres, vessels, 
and granulations enter into their composition. They are not, 
however, strictly limited from the former class, for although 
the tumour as a whole can be easily distinguished from one 
of the former class, it frequently contains particular portions 
which cannot be distinguished with certainty from tubercular 
deposition. Neither is there any strict limit between these 
and certain forms of non-malignant tumour, namely fibrous 

Pathological Anatomy, Carcinoma, fasc. 2, 3 ; and Cruveilhier's Ana- 
tomie pathologique. For the microscopical appearances we may espe- 
cially refer to J. Miiller iiber den feineren Bau der krankhaften Ge- 
schwiilste, or West's translation ; A. Hannover, Svar paa Sporgs- 
maalet, Hvad er Cancer? Kjobenhavn, 1843; Gluge's Atlas der 
patholog. Anatomie, Parts 1 and 4, and his Anatomisch-mikroskop. 
Untersuchungen, Parts 1 and 2 ; and Klencke's Untersuchungen und 
Erfahrungen, vol. ii. 



CANCER. 



291 



tumour, and cases frequently occur in which it cannot with 
certainty be determined whether a tumour belongs to the 
carcinomatous or fibrous group, that is to say, whether it be 
malignant or non-malignant. The malignancy depends here, 
as in the former class, on softening and a disintegration of 
the elements, commencing with the cellular structures, but 
gradually proceeding to the fibrous parts and the elementary 
tissues of the affected organ. 

The anatomical and histological relations of carcinomatous 
tumour exhibit the greatest variety; indeed, even in the 
same tumour, different parts often present very different 
characters. Their characters further vary with their stage of 
development. These tumours are sometimes soft, resembling 
cerebral substance ; sometimes firm, like lard ; and sometimes 
hard, like cartilage ; sometimes they are highly vascular, and 
of a reddish tint ; sometimes pale ; sometimes they are dis- 
tinctly separated from the adjacent parts, whilst in other 
cases there is no line of demarcation between them and the 
surrounding tissues. Hence in a general consideration of the 
subject, these relations are of no value. 

Moreover the histological elements of individual carcino- 
matous tumours are very different, and arranged in various 
ways. I shall therefore notice them separately. In carcino- 
matous tumours there occur : 

1. A firm, dense, amorphous substance, bearing a 
close resemblance to, and probably identical with coagulated 
fibrin. It is rendered transparent by acetic acid, and by ammonia 
and other caustic alkalies, and sometimes incloses molecular 
granules consisting of modified protein or fat. This substance 
is doubtless to be regarded as the solid cytoblastema of can- 
cer, and is subsequently converted into cells or fibres, which 
may sometimes be very clearly detected. # It is characteristic 
of a definite stage of the development of cancer, and is conse- 

* See Plate vin. fig. 9, a, b. 

u 2 



292 



PATHOLOGICAL EPIGENESES. 



quently often entirely absent in perfectly developed specimens. 
Indeed, it appears that in some cases, cancer arises only from 
a fluid cytoblastema, so that during its whole course this 
substance does not present itself. In rare cases it occurs as 
the preponderating constituent ; and then the nature of the 
cancer can only be recognized in more highly developed por- 
tions of the tumour ; or, indeed, the diagnosis may be alto- 
gether impossible. This firm amorphous substance is in itself 
not characteristic of cancer ; in fact it closely resembles and 
appears to be identical with the ordinary solid cytoblastema of 
all other epigeneses, namely coagulated fibrin. 

2. Molecular granules which appear to consist partly 
of a modified protein-compound, and partly of fat, and which 
we have already had occasion to notice as constituents of 
morbid epigeneses, occur also in cancer,* and along with 
them we frequently meet with large fat-globules and fatty 
granules. f Elementary granules consisting of calcareous salts 
appear but rarely in cancer. These molecular granules are 
sometimes entirely absent ; in other cases, namely in softened 
parts, they are very numerous, and sometimes unite into 
large masses, forming aggregate corpuscles. These structures 
are, however, not characteristic of cancer. 

3. Cellular structures form a very important class of 
elements, which are never absent in perfectly developed forms 
of cancer. They sometimes predominate to such an extent, as 
to form nearly the whole tumour, as in cases of encephaloid, 
but are only of secondary importance in hard cancer (scirrhus). 
The cellular structures occurring in cancer are of two kinds : 
a. Such as during its whole process of development can 
never exceed the cellular form. These cells — transitory cells 
according to our scheme in p. 125 — are the characteristic 
cancer- cells, b. Such as are capable of development into 

* See Plate vi. fig. 8, 11 ; Plate vni. fig. 1, 4, 6. 
f See Plate vin. fig. 4, b. 



CANCER. 



293 



other structures, namely into fibres, and therefore only to be 
regarded as cells in a transition state — developmental or 
fibre-cells. 

A. The characteristic cancer-cells present extreme variations, 
from the simple cytoblast through every modification of which 
a simple cell is capable, up to highly developed cellular 
forms — varieties which in every case depend for the most part 
on the degree of development of the primary cells, and are 
sometimes transitory, and sometimes persistent stages of 
development. The primary forms of these cells present no 
peculiarity. The nuclei vary from the 450th to the 250th 
of a line in diameter, are insoluble in acetic acid, and often 
contain nucleoli ; # the cells are nucleated and round, or oval, 
vary from the 300th to the 100th of a line in diameter,! 
entirely dissolve on the addition of the caustic alkalies, and 
disappear, with the exception of their nuclei, on the addition 
of acetic acid. 

Still more characteristic of carcinomatous tumours are the 
cellular forms, which frequently, but not invariably are asso- 
ciated with the above primary forms, and only rarely occur 
independently of them. To this class belong : 
a. Peculiarly formed, caudate, ramifying cells.j 
|3. Cells containing a large number of nuclei (from two to 
twenty or thirty) or enclosing in their interior perfect young 
cells. J They are usually of considerable size, varying 
from the 100th to the 30th, or even 20th of a line in 
diameter. 

y. Cells with a very thick wall, exhibiting a double con- 
tour. § 

* See Plate vi. fig. 8 b, 9b; Plate vin. 1 d, 4 d, 6 d, 8 a. 
f See Plate vi. fig. 7, 9, 11 ; Plate vin. fig. 1 a, 4 d, 6 a, a, b, 
8 b. 

X See Plate i. fig. 11; Plate vi. fig. 7, 8 a. 
|| See Plate I. fig. 5, 6, 7 ; Plate vi. fig. 7, 8. 
§ See Plate i. fig. 2 a ; Plate vin. fig. 6 b, 9 b. 



294 



PATHOLOGICAL EPIGENESES. 



<T. Double cells formed either by the division of one, or the 
fusion of two cells. 

i. Cells filled with granules (granular cells) and others in 
which granules appear to be scattered over the surface. # 

In some forms of cancer there also occur : 

£. Cells of various forms and sizes inclosing dark (generally 
black) granular pigment (pigment-cells) .f 

Between these different forms of cells, there occur innu- 
merable transitions, and they are all doubtless to be regarded 
as primary cells in different stages of development. Some of 
these forms occur principally in certain varieties of cancer, of 
which they may be deemed characteristic, as we shall 
presently see. Hence it follows, that of all the above forms, 
there is none that can be deemed as solely pertaining to 
cancer ; in fact that there is no such thing as a distinctive 
cancer-cell; and consequently that from observing a single 
cell under the microscope, it is impossible to decide with 
certainty whether it is cancerous or not. On examining a 
mass of these cells we can often decide with certainty on their 
being cancer-cells, from the varieties which they present, and 
from the occurrence of the above forms. 

B. The transitory cells occurring in cancer are chiefly 
fibre-cells, that is to say, they are fusiform cells prolonged 
in the same axis in both directions, such as occur in the 
development of areolar tissue, and of simple muscular fibre.J 
They occur for the most part in the firm, rarely in the soft 
forms of cancer. 

In the numerous forms of cancer which I have examined, I have 
always found these fibre-cells playing only a secondary part, and 
Hannover's experience coincides with mine. J. Miiller appears to have 
found them as the sole, or at all events as the predominating ingredient 

* See Plate vi. fig. 11 ; Plate vin. fig. 6. 

f These cells are precisely similar to the pigment-cells from a mela- 
notic lung, depicted in Plate ix. fig. 7. 

X See Plate vi. fig. 9 ; Plate vm. fig. 7 c, fig. 9 c. 



CANCER. 



295 



in many cancerous tumours.* I think, however, that the cases in 
which they predominate belong more to non- malignant (fibrous) tumours 
than to actual cancer. 

4. Fibres of various kinds form a further histolo- 
gical element of cancerous tumours. Some are perfectly 
identical with those of fibrous tumours ; these either resemble 
the fibres of areolar tissue, are very delicate, and vary in 
diameter from the 2000th to the 800th of a line, or else 
they resemble the fibres of simple, non-striated muscular 
fibre, being thicker than the former, and varying in diameter 
from the 800th to the 300th of a line. Sometimes both 
these kinds of fibres are seen perfectly developed ; in other 
cases the formation of the fibres is less distinct, the whole 
mass having an almost amorphous appearance, as if the fibres 
were blended into one another — just as we have already seen 
in the amorphous variety of fibrous tumour. As in the case 
of fibrous tumour, the fibres arise sometimes from undoubted 
cells, and sometimes from an amorphous cytoblastema in- 
dependently of any regular cell-formation. These kinds of 
fibres may be distinguished by their becoming pale on the 
addition of acetic acid, and frequently entirely disappearing, 
at least nothing but elongated oval nuclei remaining in their 
place.f 

The second kind of fibres occurring in cancer are identical 
with Henle's nucleated fibres, J and with the fibres of elastic 
tissue. They frequently present a ramifying, sometimes a 
dichotomic arrangement, and are chiefly to be distinguished 
from the preceding group by their behaviour with acetic acid — 
instead of disappearing, their outline becomes more clear and 
distinct. 

In some forms of cancer, as for instance, in encephaloid, 

* Ueber den feineren Bau, &c, p. 21, Platen, fig. 11; or West's 
translation, p. 64, Plate iv. fig. 11. 

f These fibres are shown in Plate vin. fig. 2, 3, 5, 7. 
I Allgemeine Anatomie, p. 194. 



W6 



PATHOLOGICAL EPIGENESES. 



these fibrous structures are altogether absent ; in other forms 
as for instance, scirrhus or fibrous cancer, they predominate. 
By the predominance of these fibrous structures, of which 
the former is by far the more common, cancerous tumours 
connect themselves with the formerly described fibrous tu- 
mours, and indeed it is sometimes impossible to distinguish 
whether a cancerous or a fibrous tumour had first existed. 

The arrangement of these fibres and their relations to the 
cells is also extremely variable. Sometimes the cells and 
fibres are so arranged, that on making a microscopic exami- 
nation, some parts are found to consist only of fibres, and 
others only of cells. Usually the fibres form the ground- 
work or stroma in whose interstices the cells are deposited. 
Sometimes the fibres assume a radiating arrangement, pro- 
ceeding from the centre to the periphery of the tumour, as 
for instance, in cancer of the liver. * In other cases a tissue 
with roundish meshes is formed, in which the cellular masses 
are deposited! — an arrangement very similar to that of the 
elastic tissue in the healthy human lung. In certain forms 
of cancer we observe the fibres and cells in very peculiar rela- 
tions to each other; the fibres form roundish capsules, of 
which the interior is filled with cellsj — a formation similar to 
that which occurs in certain ganglia, where also cells (gan- 
glionic corpuscles) are found enclosed in capsules composed of 
fibres. These fibrous capsules are sometimes isolated, || and are 
sometimes connected by fibres issuing from them with 
similar tissue in their vicinity. 

The formation of these singular capsules appears to proceed in the 
following manner : in the first place, there is formed a cell with a thick 
cell- wall, exhibiting a double contour. § In this, as in a parent cell, 

* See CarswelTs Pathological Anatomy, Carcinoma, fasc. 2, PI. iv. 
fig. 1. 

t See Plate vin. fig. 10. 
X See Plate vin. fig. 3 a, b. 
i| See Plate vin. fig. 3 b. 
§ See Plate vin. fig. 9 b. 



CANCER. 



297 



there is a new cell-formation, while the thick cell- wall assumes a fibrous 
character. This peculiar metamorphosis of a cell is analogous to 
nothing hitherto observed; I have, however, so frequently made the 
observations leading to this view of the case, that I regard it as beyond 
a doubt. 

This structure is chiefly formed of the fibres soluble in 
acetic acid ; those which are insoluble in that re- agent — the 
elastic fibres — occur much more rarely in cancer, and never 
in large masses. They appear also regularly arranged 
in a reticulated form, and cross-barred, or else in irregular 
meshes. 

5. Blood-vessels also form an element (although not 
an essential one) of cancerous tumours. In some forms they 
are altogether absent, in others they are present, but appear 
to belong to the normal tissue, within which the cancerous 
matter has been deposited ; as for instance, in the soft forms 
of cancer, where the newly formed cancerous matter is not 
sufficiently firm to compress the vessels of the tissues infil- 
trated by it. Some forms of cancer, on the other hand, un- 
doubtedly contain new vessels which appear for the most part 
between the fibrous elements; rarely, if ever, between the 
cells. In open cancer (cancerous sores) granulations are 
formed which are remarkably vascular; of these, however, 
we shall speak presently. The cases of cancer which are fur- 
nished with very numerous new vessels, form a distinct 
variety to which the name Fungus hcematodes has been given ; 
but many cases which have been described by different 
authors as fungus nematodes, do not in reality belong to cancer. 

In cancer as in other forms of tumour, it often becomes a disputed 
point, whether or not there are blood-vessels present. It appears to 
me that the whole question of dispute is made clear by the preceding 
observations, and indeed, after all, it is a point of no great importance. 
Some, after injections, have found only arteries, and no veins ; we may 
understand this, if we remember how much more easily the veins may 
be compressed and obliterated by the pressure of the cancerous matter, 
and likewise how much more easily they may become filled with it, than 



298 



PATHOLOGICAL EPIGENESES. 



the arteries. Whether lymphatics and nerves occur in cancer is doubt- 
ful ; if they are present, they are undoubtedly not newly formed, but 
belong to the parent tissue. 

6. Another element which enters into the composition of 
cancerous tumours — which indeed, is seldom altogether absent, 
and often occurs in very large quantity — is a viscid fluid per- 
fectly analogous to the essential constituent of the gelatinous 
tumours described in p. 236. This viscid fluid is characte- 
rised by the presence of a substance resembling mucin or 
pyin, which on the addition of acetic acid, sulphate of iron, 
or infusion of galls, coagulates into a colourless, streaky, 
amorphous mass, as may be observed under the microscope ; 
a similar but less marked effect is produced by alum, alcohol, 
and corrosive sublimate. The ultimate composition of this 
substance, its mode of origin, and its uses are unknown. 

The above elements are the essential constituents of cancer. 
In the process of softening they undergo changes which in all 
essential points are identical with those observed in the soften- 
ing of tubercle. Of these we shall speak presently. Accord- 
ing as one or other of these elements predominates, and 
according to the various modes in which they are associated 
and arranged, we have the different forms and varieties of 
cancer, which, however, cannot be strictly separated from one 
another, but exhibit every possible transition-stage. The 
most important of these forms will be presently noticed. 

In addition to the above elements, we sometimes meet 
with others which, however, do not belong to the cancer 
itself, but to the parent-tissue in which it was deposited ; 
as for instance, striated muscular fibre, fatty tissue, glands, 
&c. As many of the above mentioned elements of cancer 
occur also as normal constituents of the body — as areolar 
tissue, simple muscular fibre, elastic tissue, and vessels — it is 
not always easy to distinguish whether such elements, when 
they occur in a cancerous tumour are newly formed or belong 
to the parent-tissue. 



CANCER. 



299 



Causes j formation, development, distribution, further 
course, and consequences of cancer. 

Pathological anatomy has not yet succeeded in throwing any 
very great light on the causes giving rise to the formation 
of carcinomatous tumours. It is probable that here, as in 
the formation of other morbid epigeneses, a whole series of 
causes are in simultaneous action, and mutually checking 
one another ; these causes lying partly in the property of the 
cytoblastema, and partly in that of the organ or of the whole 
organism in which the cancer becomes developed. 

The cytoblastema of cancer, as of all other morbid epige- 
neses, arises doubtless from the blood, is originally fluid, and 
identical with the liquor sanguinis. Sometimes an increased 
quantity of blood-plasma is separated in consequence of a 
local capillary hyperemia,* arising from some mechanical 
cause — as compression, a blow, &c. In other cases, namely 
when the formation of the cancer is very gradual and imper- 
ceptible, no signs of local hyperemia can be detected, and it 
is possible that then the ordinary nutrient fluid (not increased 
in quantity, and either changed or unchanged) may by local 
influences be converted into cancer. In some cases the cyto- 
blastema appears to remain fluid, and in this fluid condition 
to undergo development ; in other cases it coagulates before 
the commencement of development, and the cancerous matter 
is formed, either wholly or in part, from a solid cytoblastema.f 

The circumstance of the coagulation shows that the 
cytoblastema consists, in a great measure, of fibrin. The 
solidification of the cytoblastema yields one of the histolo- 
gical elements of cancer, namely the solid amorphous sub- 
stance. But since there is nothing characteristic in this 
mass — for, indeed, it is perfectly identical with the coagulated 
exudation of fibrinous dropsy — it is impossible from it alone, 

* As in the case illustrative of Plate vni. fig. 9 ; and I have met 
with many similar cases, 
t See Plate vni. fig. 9. 



300 



PATHOLOGICAL EPIGENESES. 



to diagnose the presence of cancer ; indeed, this is only pos- 
sible when other parts of the tumour are in a more advanced 
stage of development. 

Moreover, the molecular granules described as a second 
constituent of cancer, are formed (in part, at least) at a very 
early period, and probably in a fluid as well as in a solid cy- 
toblastema. Their formation is undoubtedly dependant on 
some (still unknown) chemical peculiarity of the cytoblastema, 
as on its containing a superabundance of fat, or some pecu- 
liar modification of one of the protein-compounds. When 
these conditions are not fulfilled, the molecular granules are 
altogether absent, or are only very sparingly present.* These 
primary molecular granules must not be confounded with 
those which make their appearance during the process of 
softening, and of which we shall discourse presently. 

The further development of cancer consists in the organi- 
zation of the cytoblastema, and in its conversion into the cells 
and fibres, which we have already described.! In this early 
stage, the formation of vessels is probably extremely rare. 
It is not easy to trace the development of the cells, for, in 
general, from the very first we observe them of very different 
forms, and apparently in various stages of development. 
Sometimes, in the examination of a cancerous tumour, we 
observed very large knotty masses, varying in diameter from 
the 30th to the 10th of a line, or even larger, containing 
irregular cells, and exhibiting a tolerably distinct outline. 
They probably have the same signification as the large cells 
already described, in whose interior young cells are formed, 
while the cell- wall becomes converted into fibrous tissue. The 
fibres soluble in acetic acid, arise partly from undoubted fibre- 
cells, and partly from the amorphous blastema without any 
definite cell-formation. No certain observations have yet 

* See Plate viii. fig. 9. 

t We have attempted to depict this early stage of development from 
a solid, amorphous cytoblastema, in Plate vin. fig. 9. 



CANCER. 



301 



been made regarding the formation of elastic fibres ; they 
appear, however, in some cases to arise from a channelled or 
reticulated thickening of the solid, membranous cytoblaste- 
ma. Regarding the chemical metamorphosis of the blastemal 
fluid, by which the viscid substance of which we have made 
mention, and which is of such frequent occurrence in cancer, 
arises, we cannot offer even a probable conjecture. 

Hence it follows that cancer is a thoroughly morbid epige- 
nesis, and is not in the smallest degree produced by a meta- 
morphosis of the tissues between which it is developed. 
Another question to be considered is : What influence do the 
surrounding parts exercise on the development of cancer ? 
I mean by this, not the altogether unknown influence which 
the modified energies of the tissues doubtless exhibit in the 
formation of cancer, but simply the influence which the 
parent-tissue exerts on epigeneses in accordance with the law 
of analogous formation. An influence of this nature can have 
no weight in the formation of cancer-cells, since they are 
heterogeneous tissues, and their first appearance can be as 
little explained by that law, as the appearance of pus- corpus- 
cles, On the other hand, the fibrous structures and the 
vessels of cancer may very possibly be formed by the influ- 
ence of the surrounding parts, in accordance with the law of 
analogous formation — at least in those parts which in their 
normal state contain vessels. According to this view, those 
kinds of cancer which contain fibres must be regarded as a 
combination of malignant tumour containing cells, with 
non-malignant fibrous tumour, and we shall show, in a 
future part of this work, the importance of it, for the more 
the fibres predominate in a cancerous tumour, so much the 
more innocuous and less malignant do we generally find 
it. 

The cancerous matter occurs between original elemen- 
tary parts of the parent-tissue, and occupies, more or 
less perfectly, all the interstices. A slight infiltration of can- 
cer in a tissue, frequently escapes the observation of the un- 



302 



PATHOLOGICAL EPIGENESES. 



aided eye, and can only be detected by careful microscopic 
examination — as for instance, in fatty tissues. * When the 
interstices are not thoroughly filled, and the cancerous deposit 
is soft, the parent-tissue, at least in the first stage, is com- 
paratively little injured. If, on the other hand, the infiltra- 
tion is complete and the cancerous deposit very firm and 
solid, then the elements of the tissue become compressed, 
appearing to be blended with the deposit into a homogeneous 
mass, and gradually become atrophied and disappear. This 
disappearance of the elements of the tissues by atrophy 
and resorption, which is peculiar to the first stage of cancer, 
previous to softening, must be clearly distinguished from the 
destruction of the entangled tissue, which is dependant on 
the softening of cancer, and of which we shall speak pre- 
sently. It is beyond all doubt that by the gradual increase 
of a cancerous tumour, the parts in its vicinity must be dis- 
placed ; this applies, however, more to whole organs than to 
the elements of tissues, and is much rarer than is usually 
supposed. Thus, for instance, in cancer of the liver the 
hepatic cells do not become displaced, but get enclosed in the 
cancerous deposit, and thus gradually become atrophied. 

Finally, after its full development, the cancer proceeds to 
soften ; the process being essentially identical with that 
occurring in tubercle, and which we have already described. 
It proceeds in cancer, even independently of cell-formations. 
It is only in those cases where other processes — as gangrene, 
tubercle, or typhous deposit — are combined with cancer, that 
the amorphous blastema around and in the cancerous tumour 
breaks up directly, without the previous formation of cells. 
These separate from one another, break up, and form a quasi- 
purulent fluid, which sometimes contains decided (although 
partially injured) cancer-cells, and sometimes a mere detritus, 
consisting of molecular granules, crystals of cholesterin, &c, 
perfectly similar to softened tubercle. On what this disinte- 

* See the description of Plate viii. fig. 6, 7. 



CANCER. 



303 



gration depends, is unknown ; it appears to be dependant on 
the nature of the process itself* — as in the formation of pus 
from a solid cytoblastema — for although it can be hastened or 
retarded by external influences, it cannot be entirely arrested. 
As a general rule the softening proceeds very gradually, com- 
mencing at individual points of the tumour, often at several 
simultaneously. A section of the tumour at this stage, 
shows at one or several spots collections of purulent fluid, 
consisting of softened cancer-cells. I think it is not impro- 
bable that these points at which the softening commences, 
when they are very minute, and at the same time very few, 
gradually disappear by resorption, the slight loss of substance 
healing by cicatrization, and the injurious progress of the can- 
cerous tumour, being thus prevented; this, however, only 
occurs in those forms of cancer which consist for the most 
part of fibres, and contain only a few cells. The ordinary 
course of a cancerous tumour is very different ; the softening 
continuing to progress, and thus gradually extending to the 
whole cellular structure within the tumour. In this manner 
the minute and isolated specks of pus enlarge, and by uniting, 
form large masses, (such as occur in the formation of ab- 
scesses,) till finally the collected fluid forms for itself an 
external outlet, thus converting occult into open can- 
cer. But further, another change occurs in the softened 
cancerous matter ; it undergoes chemical modifications, 
becomes decomposed, acrid, fetid, and of an unhealthy 
appearance ; in short, the softened cancerous matter becomes 
converted into an ichorous discharge, the chemical properties 
of which are not accurately known, and probably vary in dif- 
ferent cases. These changes, like those of an analogous 
character occurring in tubercle, are dependant on a species of 

* Vegetable physiology furnishes us with an analogous proceeding in 
the normal softening of many fruits (as for instance, that of solanum 
nigrum) which depends on a separation and solution of the (merenchy- 
ma) cells forming their tissue. 



304 



PATHOLOGICAL EPIGENESES. 



putrefaction, of which the conditions have not yet been 
accurately investigated ; but — as in that case — probably are 
a large quantity of the product of the softening, impeded 
metamorphosis in the surrounding parts, and an admixture 
of matter inducing putrefaction — namely blood. Until the 
commencement of the ichorous discharge, the softening is 
usually restricted to the cellular portions ; at the same time 
the solid parts, namely the fibres and blood-vessels, which 
in themselves have no tendency to soften, undergo putrefac- 
tion and disintegration through the influence of the ichor ; 
their destruction is, however, usually very gradual. In this 
stage, a section of those forms of cancer which contain fibres 
presents a very peculiar appearance. It exhibits irregular 
cavities filled with ichor, whose walls are very tough, often 
as hard as cartilage, and are composed of fibres, presenting, 
as it were, a corroded appearance. Isolated fibrous bundles 
frequently softened and half destroyed at their superficies pro- 
ject into the cavities, or extend across them in the form of 
rafters or arches. We sometimes discover the open mouths 
of corroded blood-vessels; in these cases effused blood, 
coagulated in clots or mixed with ichor, fills the cavities. 

The above series of processes occurring in the development 
of cancer, occupy very different periods of time in different 
cases ; they always require several weeks or months, and 
sometimes several years. In proportion to the extent of 
cellular structure in a case of cancer, so much the more 
quickly does the process of development attain its termination, 
and it has long been remarked that the forms of cancer, in 
which cells predominate, (encephaloid) usually run their 
course and terminate fatally in about as many months as 
those forms in which fibres predominate (scirrhus) require 
years. 

Simultaneously with the process of development the cance- 
rous tumour undergoes other changes ; it increases to such a 
degree, that from a very limited origin it often becomes 
distributed over a large space, occupying one or even several 



CANCER. 



305 



organs. This enlargement is undoubtedly dependant on 
the cellular structure of the cancer, and probably also 
on the fibres acting upon the nutrient fluid in the neigh- 
bouring parts, in accordance with the law of analogous for- 
mation. The increase of the cancerous cells is forwarded by 
the circumstance that many of them act the part of parent- 
cells, and contain in their interior young cells, which in all 
probability are capable of a similar mode of increase. More- 
over, the numerous cytoblasts frequently observed in a cell, 
probably all become themselves developed into distinct cells. 
With these facts before us, there is clearly no limit to the 
increase of cancer-cells, neither is there any necessity for 
regarding them as distinct organisms similar to the lowest fungi 
and algae. It is clear, however, that the fibres and the vessels 
(if any are present) cannot be increased by means of the 
cancer-cells ; in all probability the increase of the fibres — and 
in fibrous cancer such an increase undoubtedly occurs — is 
dependant upon the influence of the pre-existing fibres, just 
as is the case in the growth of pure fibrous tumours. The 
innate capacity for augmentation possessed by cancer, is 
very energetic, and forms an essential distinction between 
cancerous tumours and scrofulous depositions; for in the latter 
this capacity is either altogether absent, or only present to a 
very slight degree. Hence the growth of cancer is most 
rapid when an increased cytoblastema is yielded to it from 
any source, as for instance, from inflammatory exudation, 
especially from fibrinous dropsy in the adjacent parts. It always 
increases on the supervention of softening and ichorous dis- 
charge, in consequence of the irritation to which these pro- 
cesses give rise in the surrounding parts. The exudation thus 
yielded by the neighbouring hypersemic parts is converted into 
cancerous matter, and hence cancer is not, as is frequently 
the case with tubercle, separated from the surrounding parts 
by granular cells or pus, nor is it retarded in its growth by a 
line of demarcation. The newly-formed cancerous matter 
goes through precisely the same course of development as 
vol. i. x 



306 



PATHOLOGICAL EPIGENESES. 



the original ; proceeding of necessity to softening. In some 
cases, we find the peripheral portion of the cancerous matter, 
and the surrounding parts contending, as it were, for the 
cytoblastema, and sharing it between them. There are 
formed, as may be observed in cancerous ulceration, fungoid 
and extremely vascular granulations ; but these are always so 
infiltrated with cancerous matter, that, after a very brief exis- 
tence, they soften and become disintegrated, never contri- 
buting to the formation of persistent tissues. 

Distinct from this local enlargement of cancerous 
tumours, there is another mode of increase, which usually 
occurs in the latter stage as softening commences, 
or sometimes earlier. There are formed other cancerous 
tumours distinct from the original tumour, often many in 
number, some being situated in close proximity with the 
original seat of the disease, namely in the adjacent lymphatic 
glands, whilst others occur in remote parts of the organism. 
The causes of this distribution of cancer are still very obscure 
— an obscurity which is increased by the circumstance that 
we are in a great measure ignorant of the causes of the pri- 
mary deposition. Doubtless the same cause which gave rise 
to the first tumour, influences the formation of the others. 
This cause appears to be in operation when, long after the 
removal of a cancerous tumour — often years after, and when 
the wound caused by the operation had long healed — a new 
cancerous tumour becomes developed in another part of the 
body. To this cause we usually apply the term cancerous 
diathesis, a phrase against which no objection can be raised, 
since it is merely the expression of an unknown fact, just as 
x represents the unknown quantity in an unsolved equa- 
tion. 

Another mode in which a cancerous tumour may increase, 
has been noticed by B. Langenbeck.* When cancer-cells 
make their way into the veins and lymphatics opened by the 



* Schmidt's Jahrbucher, vol. xxv. p. 99, &c. 



CANCER. 



307 



softening of the cancer, and thus enter the circulation, which 
is by no means a rare occurrence, they become retained in 
the smaller capillaries, in consequence of their size, and thus 
becoming further developed at these points, give rise to 
secondary cancerous tumours. Langenbeck succeeded in 
inducing secondary cancerous tumours in the lungs of a dog, 
by injecting into its blood-vessels fresh cancer-cells from a 
tumour while still warm, which had been removed two hours 
and a half previously from the humerus of a man. A can- 
cerous tumour being once formed, its distribution in this 
manner, into different parts of the same individual, is by no 
means unlikely ; but it is undoubtedly not the only way in 
which it can be extended, and it admits of several very serious 
objections. 

After this notice of the development and extension of 
cancer, we are now prepared to consider its consequences to 
the organism. These vary in accordance with the stage of 
progression of the tumour. In the first place, previously to 
the commencement of softening, they are purely local, and 
frequently barely perceptible. The cancerous matter is inju- 
rious to the adjacent elementary textures simply by its pres- 
sure and by its checking their nutrition, and these symptoms 
are the more urgent in proportion to the firmness of the 
tumour, and to the closeness with which it includes the ele- 
ments of the parent-tissue ; these causes frequently leading to 
the atrophy, and occasionally to the disappearance of these 
elements. Sometimes we observe especial phenomena from 
the pressure exercised on a neighbouring organ, on a nerve, 
or on a canal ; these are, however, simply mechanical effects, 
and not to be distinguished from those to which non-malignant 
tumours might give rise. 

On the supervention of softening, the consequences become 
more serious ; we now usually observe an (inflammatory ?) 
reaction of the surrounding parts, and the tumour commences 
to be painful. Still more injurious are the effects of the 
unhealthy suppuration which ensues ; the surrounding parts 

x 2 



308 



PATHOLOGICAL EPIGENESES. 



being affected by the ichorous discharge ; the blood-vessels 
and lymphatics in the tumour and in its vicinity becoming 
destroyed ; and the veins, unless they had previously been 
obliterated, often giving rise to such very serious haemorrhage, 
as to threaten life itself. 

The softened cancerous matter may enter the veins 
and lymphatics, and give rise to inflammation of those 
vessels, and its consequences. Cancer-cells may, also, as 
we have already mentioned, enter into the circulation, and 
becoming deposited in the capillaries, give rise to secon- 
dary cancerous tumours. But independently of any laceration 
of the vessels, the fluid portion of the ichorous discharge 
may enter into the blood by endosmosis, and induce changes 
in it, in a manner not at present understood. To this pas- 
sage of the ichorous discharge into the blood, there are usually 
ascribed a series of general symptoms, which are frequently 
noticed in the later stages of cancer, and known collectively 
as cancerous cachexia ; the chief of these are a peculiar, yel- 
lowish grey colour of the skin, disturbances in the nutritive 
process, and in the functions of the nervous system. It need 
scarcely be mentioned that the degree to which these symp- 
toms are developed is proportional to the amount and the 
malignancy of the ichorous fluid which enters the blood. 
Hence it follows that in encephaloid, which softens rapidly, 
yields a large amount of ichor, and is tolerably vascular, the 
course of events is much more rapid and severe than in 
scirrhus. That under these circumstances, the vital powers 
must become exhausted, and death sooner or later occur, 
appears to be perfectly self-evident. 

Such being the course and the consequences of cancer, we 
can readily understand the advantages to be gained by the 
surgical removal of the tumour, or its destruction by means 
of caustics ; in fact its pathological anatomy indicates the 
mode of treatment. Since, as we have seen, every true can- 
cerous tumour is continuously increasing, and nature has not 
adopted any means of limiting its growth, as we observe in 



CANCER. 



309 



tubercular and some other tumours, we see a theoretical in- 
dication of the necessity of an operation — a view confirmed 
by practical experience. It likewise follows that every extir- 
pation or destruction by caustic must be radical, for other- 
wise the remaining cancerous matter enlarges after the opera- 
tion, and, in consequence of the more abundant secretion of 
cytoblastema, grows more rapidly than before. It is only 
after the entire removal of the cancerous matter, that the 
influence of the surrounding healthy parts can induce normal 
granulations, and lead to cicatrization. If the surrounding 
parts are not in a healthy condition, or the original cancerous 
diathesis not eradicated, then even after a perfect operation, 
a cure will not result. The accurate determination of these 
cases must be left to the judgment of the surgeon. Since 
the most injurious consequences are dependant on the occur- 
rence of softening and unhealthy suppuration, it is expedient 
that the operation should be performed, if possible, before 
these changes ensue. It is very true that previously to these 
changes taking place, the diagnosis of a cancerous tumour in 
the living body is very uncertain ; but still it is far better that 
we should run the risk of occasionally extirpating a harmless 
tumour, than that, by delaying the operation, the patient be 
subjected to the risk of certain destruction. 

Cancerous matter appears to be sometimes deposited in 
other tumours originally of a non-malignant character ; these 
subsequently become converted into cancerous tumours, or 
form combinations of cancer with the preceding groups. 

I have hitherto avoided entering minutely into the question regarding 
the causes of cancer, in order that I might not interfere with the conti- 
nuity of the subjects discussed in the preceding pages. The parasite- 
theory appears to afford an obvious and intelligible mode of accounting 
for the formation of this adventitious product. According to this view, 
the cancer-cells are independent organisms, (or according to Klencke's 
nomenclature semi-individual cells,) in all cases possessing the property, 
when conveyed into the interior of the living body, of there further deve- 
loping themselves, and forming cancerous tumours. We may, therer 
fore, explain the primary formation of cancer by assuming that a 



310 



PATHOLOGICAL EPIGENESES. 



cancer-cell accidentally getting into the body, gives rise to the develop- 
ment of a tumour of this description. This view is principally sup- 
ported by experiments with inoculation, in which local cancer has been 
produced by transmitting recent cancer- cells into the organism, as in the 
experiment of B. Langenbeck to which we have already alluded. But 
on close consideration, it appears that very weighty doubts suggest 
themselves against our acceptation of the view, that all primary cancers 
arise in this manner, even if we allow that in every inoculation- experi- 
ment actual cancer is produced, and not merely a tumour of some other 
kind, such as we frequently meet with in the examination of the dead 
body after injuries. Although I have no reason to doubt the accuracy 
of Langenbeck's experiment, yet in other cases, the necessary microsco- 
pic examinations are wanting. If, further, cancer- cells can serve to 
transmit cancer from one individual to another, when they have got into 
the interior of the organs (that is, within their parenchyma), the ques- 
tion then suggests itself — how can they, under ordinary conditions, get 
there ? Even if we assume that they can be distributed into the sur- 
rounding atmosphere from open cancer, in the same manner as the 
spores of algse and fungi (which, however, is very improbable, since 
the cancer-cells, are for the most part, tolerably large, and exceed the 
100th of a line in diameter), and are deposited on the outer or inner 
surfaces of the body, still they are not in the parenchyma of the organs, 
and they can only enter, if there are wounds or lacerations, which as a 
general rule do not precede the formation of cancer. Moreover, in this 
system of propagation we must assume that the cancer-cells retain their 
vitality for a considerable period after their removal from the organism, 
and that they remain unaffected by external influences, such as a lowered 
temperature, dessiccation, &c. 

I will mention one experiment which appears to bear strongly on this 
point. From the body of a man who died from encephaloid of the tes- 
ticle, which had extended itself along the vertebral column as far as the 
diaphragm, and formed a veiy large tumour, I took, about thirty hours 
after death, a portion which contained an immense number of uninjured 
cancer-cells, expressed from the soft mass some of these cells, mixed 
them with luke-warm water, and filtered the fluid through a piece of 
linen, in order to remove any large clots which might mechanically 
tend to close the capillaries. The fluid thus prepared, contained millions 
of perfectly integral cancer-cells, averaging the 100th of a line in 
diameter, together with numerous molecular granules, besides fluid 
albumen and fat ; from its odour there was not the slightest indica- 
tion of putrefaction. This fluid was injected into the jugular vein 
of an adult healthy dog, so that I am convinced that at least thousands, 
Very probably millions of cancer- cells were thrown into the circulation 
of this animal, With the exception of the respiration being disturbed 



CANCER. 



311 



for the first few minutes after the operation, the dog exhibited no 
morbid symptoms, and when killed eight months afterwards, not the 
slightest change could be detected in any organ, although a single cell 
might, according to this view, have given rise to the development of 
cancer. This experiment (like others undertaken by Valentin, Dupuy- 
tren,* &c, with similar results) shows that cancer-cells lose their 
capacity for development very shortly after their removal from the body 
or after death, and tends to render it extremely improbable, that cancer 
should often be propagated in the above manner. But many other 
experiments are opposed to the production of cancer by contagion, as 
for instance, the cases in which it arises from mechanical influences, 
as a blow or a fall. On these grounds, the view that cancer is formed 
by the transference of cancer-cells, appears to the unprejudiced investi- 
gator, to be very improbable ; at least this mode of formation can at 
most only occur in a very restricted class of cases. But on the other 
hand, this view seems better adapted to explain the further distribution 
of cancer in an individual already suffering from it. And yet on close 
examination doubts arise regarding even this limited application, as may 
be seen by a reference to the explanation of fig. 9 in Plate viii. In 
this case cancer of the lungs succeeded the primary affection of the 
testicle. 

Here the recent cancer consisted of a solid cytoblastema, which was partly 
amorphous and partly becoming cellular, there being only a few spots 
in which perfect cancer- cells could be discovered. If I allow that here 
one or several cancer- cells became impacted in the same capillary ves- 
sels, and gave rise to exudation, it still remains problematical how a 
few cells could exert so strong an influence on a proportionally large 
mass of exudation as to convert it entirely into cancerous matter, 
whilst, in other cases, the plastic force of an organic cell is limited to 
its most immediate vicinity. And here arises a second doubt. Many 
cancers consist not merely of cells, but also contain fibres. How do 
these fibres arise ? We may, indeed, assume that in certain cases 
the cancer* cells are converted into fibres ; but, from numerous experi- 
ments, I am induced to believe that such an assumption is altogether 
false, since it is the peculiar nature of cancer-cells not to enter into other 
forms, but to undergo disintegration. Langenbeck,f however, asserts 
that he has observed that after transmitting cancerous matter into the 
circulation of a dog, cancer consisting not merely of carcinomatous 
cells, but also of " very strong, clear, juicy fibres" has formed in the 
lungs. But how can he explain their production as due alone to the 
influence of the cancer- cells ? These remarks afford a sufficient refuta- 

* Compare Hannover, Hvad er Cancer? p. 91. 
t Op. cit. p. 104. 



312 



PATHOLOGICAL EPIGENESES. 



tion of a hypothesis respecting the formation of cancer, which has 
recently been regarded by many, without sufficient examination, as 
based on indubitable evidence. In opposition to this view, there is 
nothing to hinder us from assuming that cancer- cells are originally 
formed in the body, like other cells which occur in morbid epigeneses, 
as, for instance, pus- corpuscles. 

But the conditions giving rise to one or other form of cell are still for 
the most part unknown ; and I deem it unnecessary to submit to a 
similar examination the other opinions which have been promulgated 
regarding the causes of cancer, since they would lead us too far from 
our subject, and afford no valuable results. 

Attempts of this kind finally lead to the subject of miasm, contagion, 
&c. — points which belong rather to general pathology than to patholo- 
gical anatomy. The preceding observations respecting its propagation, 
lead to the belief that cancer proceeds chiefly from the vascular system, 
namely, from the veins — a view supported by certain anatomists, and, 
amongst others, by Cruveilhier. The cancerous matter observed in the 
veins is certainly very rarely formed there as a primary product, but is 
usually secondary, depending on a propagation of the cancerous matter 
in the blood. Indeed, in many cases no cancerous matter is observed 
in them, but merely pale coagula of fibrin, similar to those which 
occur in phlebitis : this has been shewn by Hannover.* The assertion, 
that cancer can only form in certain organs, as, for instance, in cellular 
tissue, is negatived by direct observations. For other views on the 
subject of cancer, and for the literature with which they are supported, 
we must refer to J. Muller's original work, or to Dr. West's transla- 
tion. I must here revert to the opinion maintained for many years by 
Hodgkin, and still again recently f brought forward by him in opposition 
to the view that cancer is formed from the cells. 

It consists essentially in this — that all cancerous tumours both in 
man, and in the lower animals, arise from the compound cysts already 
described . 

The following considerations may serve as a clue to the correct esti- 
mation of this view, which appears to me to contain much truth, 
although not to admit of the general application that Hodgkin supposes. 
We have already seen that cysts may arise from morbid blastemata 
under very different relations, when the surrounding parts or the peri- 
pheral portion of the blastema become organized. The same may 
happen in certain cases when the greater part of the blastema is con- 
verted into a pseudoplasma ; the cancer may then be associated with 
a more or less complicated cyst-formation. Moreover, those forms 

* Op. cit. p. 86. 

t Medico- Chirurg, Transactions, 1843, p. 242= 



CANCER. 



313 



in which masses of cancer- cells appear to be enclosed in fibrous 
capsules, indicate the possibility of such processes. In this sense, 
Hodgkin's opinion appears, at all events, as established, and 
deserving of the consideration of future investigators. But, on the 
other hand, we must not conclude with Hodgkin, that all pseudo- 
plasmata proceed essentially from compound cysts. We can certainly 
never succeed in recognizing this structure in the infiltrated forms of 
tubercle, encephaloid, and scirrhus. Again, when cysts occur together 
with the pseudoplasmata, the latter do not arise from the former, but 
both are formed simultaneously. The cysts render the pseudoplas- 
mata more complicated, and exert an influence on their form, but have 
nothing to do with their production. It is on this point that the 
objection is based which Professor Grose of Cincinnati, has urged 
against Hodgkin, namely, that there is an essential difference whether or 
not the contents are produced by the wall of the cyst. If it is 
assumed that the membrane of the cyst gives rise to the pseudoplasma, 
such an opinion is just as false as that all tubercles arise from hydatids. 

In the explanation of these points we must not refer to cystoid of 
the ovary; for, in consequence of the structure of the graafian vesicle, pecu- 
liar conditions are there present ; in fact, these vesicles may be regarded 
as normal cysts, differing, however, in character, from those of any 
other part of the body. In an excellent memoir recently published by 
Engel,* the very praiseworthy attempt to explain, on physico-chemical 
principles, the formation and development of cancer, has been made in 
the same manner as was formerly done in the case of tubercle. I 
believe that here, as in that case, this is the path the exact investigator 
must follow ; but the difficulties in this case are greater even than in 
the former, because cancerous tumours are generally much more highly 
organized than tubercle, and the modification of the blood, which is 
assumed by Engel to be the basis of the formation of cancer, not merely 
requires confirmation, but an accurate chemical examination. Our 
chemical knowledge of cancer is very slight ; the older observations, as, 
for instance, those of Lobstein, are at present of little value. More 
recently, J. Miillerf and SchererJ have occupied themselves with 
its chemical investigation, but their results have not thrown any 
great light on the subject. In the chemical analysis of cancer, 
as in that of all other organic structures, the most essential point to 
attend to is, that the chemical and histological investigations should 

* Zeitschr. d. Gesellschaft d. Aerzte zu Wien. Jahrg. i. p. 267, &c. 
t Op. cit. p. 24, or West's Translation, p. 73, where the analyses of 
the earlier chemists are quoted and criticized. 
% Untersuch, p, 220, 



314 



PATHOLOGICAL EPIGENESES. 



proceed hand-in-hand, and that we should endeavour to give a suitable 
account of the seat, form, and signification of each substance recognized 
by the chemical analysis. Cancer, however, consists of solid portions 
infiltrated with fluids : these solid portions are an amorphous blastema 
(probably fibrin), elementary granules (whose chemical composition has 
been already considered), fibres, and cells. In chemical composition the 
fibres are probably identical with those that occur in fibrous tumours, and 
must be regarded as forming an intermediate link between the protein- 
compounds and gelatigenous tissues. The composition of the cancer-cells 
is still unknown ; it doubtless varies with their development. The fluid 
constituents of cancer are, undoubtedly, extremely various, according as 
the tumour is crude, softened, or discharging. Hence, to complete 
our knowledge of the subject, a large number of analyses is requisite, and 
we proceed on a very false principle, in attempting to deduce general 
conclusions from isolated investigations. We shall return to this subject 
in our remarks on the different forms of cancer. For statistical 
information relative to cancer, we must refer to Herrick and Popp,* and 
Leroy d'Etiolles.f 

The diagnosis of cancer in a pathologico-anatomical point 
of view, is in many cases very easy, whilst in others it is 
extremely difficult, and, indeed, almost impossible. Even 
after its extirpation, or in the dead body, when we can examine 
it at our leisure, and with all our aids to diagnosis, we 
cannot always decide with certainty on its nature. In this 
case, as with the former tumours, our diagnosis must be based 
not so much on the coarser physical characters which in cancer 
are liable to extreme variations, as on the histological relations 
as viewed through the microscope. The diagnosis must be 
based : 

1. On the peculiarity of the development of the tumour, 
namely, on its softening. But softening may also occur in 
other tumours, as in tubercular tumours, and in cases of 
unhealthy, malignant suppuration, accompanied by loss of 
tissue and induration of the surrounding parts. Here we 
must adopt the second of our means for diagnosing cancers : 
we must search for the cancer-cells which are characterized by 

* Ueber bosartige Fremdbildungen. Regensburg, 1841. 
t Gazette Med. de Paris. Mars, 1843. 



CANCER. 



315 



their form and size, and by the number of cytoblasts and 
young cells, and may be readily distinguished from pus-corpus- 
cles, as well as from the indefinite cellular structure of 
tubercular swellings. In most cases the softened cancerous 
matter exhibits these cells, or fragments of them ; but when 
these are absent, and when the cancer-cells generally are not 
perfectly formed, then a certain diagnosis is impossible ; and 
the difficulty is, if possible, increased in those cases where a 
tumour approximates equally to cancer, tubercle, and unhealthy 
suppuration. Hence it is sometimes impossible to distinguish 
whether we are examining an open cancer, or some other foul 
ulcer. It is not in accordance with the principles of human 
reason to erect an arbitrary and constrained distinction, where 
nature herself has fixed no definite limit. 

2. Before the commencement of softening, the diagnosis 
is exclusively founded on the presence of cancer-cells ; and it 
is certain, in proportion to their abundance, preponderance, 
and perfect condition, and to the facility with which they 
admit of being distinguished from other primary or develop- 
mental cells. The irregular caudate cells # are especially 
characteristic, as also are the large cells with many cytoblasts 
and young cells,f the cells with a thick wall,| and the accu- 
mulations of cells in fibrous capsules. § The other forms of 
cells are very slightly or not at all characteristic, since they 
occur in the development of other tumours ; thus, for instance, 
the elongated fusiform cells || occur also in the strictly fibrous 
tumours. Hence, when a cancerous tumour is met with at a 
very early stage, and the amorphous cytoblastema predomi- 
nates, or the cells assume a primary form, and present no 
marked characteristics, the diagnosis is very problematical. 
Another circumstance, rendering the diagnosis uncertain, 
presents itself when the cells are secondary in quantity to 

* See Plate i. fig. 11. f See Plate vi. fig. 7, 8. 

t See Plate viii. fig. 6. b. § See Plate vni. fig. 3. b. 

|| See Plate viii. fig. 9, c. 



316 



PATHOLOGICAL EPIGENESES. 



fibres or other structures. In this case, however, the 
uncertainty of a true diagnosis is only apparent ; for such 
tumours lie in reality between cancer and non-malignant 
fibrous tumour ; they are a combination of the two forms, 
and become innocuous as the latter predominates. The 
relations are very similar with the combinations of cancer with 
melanosis and vascular tumour. 

Several cases illustrative of the diagnostic value of the microscope in 
relation to cancer in its various stages, are given in the description of 
the plates to the second volume. Further observations on the diagnosis 
of cancer will be found in our remarks on the individual varieties. 
With respect to its surgical diagnosis, and the detection of cancer of 
the internal organs during life, we shall add nothing further in the 
present place, since they are based on many phenomena which are not 
included in the domain of pathological anatomy. 

FORMS AND VARIETIES OF CANCER, 

Cancerous tumours, although they all exhibit the essential 
characters of carcinoma, yet in their physical properties and in 
the arrangement of their histological elements, present the 
greatest varieties, which are, however, dependant on two 
causes : 1, on the organ in which the tumour is developed — 
a point to which we shall return in the second volume ; and, 
2, on a difference in the arrangement of the histological 
elements entering into the formation of the tumour. These 
differences we shall consider at some length. In the exami- 
nation of a cancerous tumour we sometimes find cancer-cells, 
and sometimes fibrous tissue predominating, and the degree of 
development of these tissues also varies in different cases; some- 
times the principal constituent is a firm, amorphous cytoblaste- 
ma, and occasionally the most abundant ingredient is a viscid 
tenacious fluid. This is the case not merely with different 
cancerous tumours, but it is even observed in different parts 
of one and the same tumour ; so that frequently, indeed most 
commonly, on taking two neighbouring sections, we find that 
they present very different physical properties, and a perfectly 
distinct histological arrangement. Attempts have been made 
to regard these differences as different species of cancer ; but 



ENCEPHALOID. 



317 



here, as we have already shewn in the case of the other 
tumours, a division into species, such as is adopted in natural 
history, is impracticable : like many minerals, cancer presents 
a group of forms merging into one another without any fixed 
line of demarcation, the individual constituents being, to a 
certain degree, vicarious, and reciprocally displacing one 
another. The following are the chief of these forms : 

FIRST FORM. 

CELLULAR CANCER ENCEPHALOID,* 

Synon. Medullary sarcoma; fungus medullaris ; cancer meduHaris ; 
carcinoma medullare ; milk -like tumour. 

Encephaloid is that variety of cancer in which the cancer- 
cells predominate over the remaining histological elements of 
the tumour. It appears to be generally developed from a 
fluid cytoblastema, and hence in examining it during its early 
stages of development, we rarely find the firm, amorphous 
cytoblastema, which is usually met with in other forms of 
cancer. The fibrous tissue is never so prominent an ingre- 
dient as the cancer-cells ; indeed, in some cases it appears to 
be altogether absent, so that the cancer-cells are directly 
deposited between the normal histological elements of the 
affected organ; more frequently, however, it occurs in a 
Subordinate degree, forming a stroma in which the cancer- 
cells lie. When the fibres predominate, encephaloid merges 
into fibrous cancer, and we sometimes observe that while one 
portion of a tumour resembles encephaloid, another more 
closely approximates to fibrous cancer. The viscid fluid 
likewise occurs almost constantly in encephaloid after soften- 

* Compare J. Miiller, iiber den feineren Bau, &c, p. 19 ; or West's 
translation, p. 58 ; Hannover, Hvad er Cancer ? p. 9 ; G. Gluge, Atlas 
der pathologischen Anatomie, Part 1 ; Valentin, Repertor. vol. n. p. 277. 
The three first works give a tolerably perfect sketch of the previous lite- 
rature of the subject. 



318 



PATHOLOGICAL EPIGENESES. 



ing ; it is, however, rarely the leading constituent ; in these 
cases encephaloid approximates to gelatinous cancer. In 
consequence of the extreme softness of its elements, ence- 
phaloid compresses the parent-tissues in a less degree than 
solid cancer. It admits of the passage of blood-vessels 
through its structure, and as they do not become obliterated 
so frequently as in fibrous cancer, its appearance is usually 
vascular. In some cases newly-formed vessels occur in it. 
When, during the softening of encephaloid, the vessels become 
opened, the effused blood more readily enters the soft tissue, 
and mixes with it, than in the harder sorts of cancer ; the 
whole mass assumes a sanguineous appearance, and in this 
way encephaloid merges into fungus haematodes ; it must, 
however, be observed, that the term fungus haematodes is 
applied to many tumours which have no connexion with ence- 
phaloid, as for instance, telangiectases and other non-malig- 
nant vascular tumours. 

Black granular pigment may likewise enter into the com- 
position of encephaloid, forming melanotic cancer (carcinoma 
melanodes). 

There are certain forms of cancer-cells which are characte- 
ristic of encephaloid, for instance, parent-cells with young 
cells in their interior, cells with numerous cytoblasts, # and 
the irregular caudate and ramifying cells.f My own experience 
leads me to assert that these forms are not often found in 
other forms of cancer ; but, on the other hand, they do not 
occur in all cases of encephaloid. 

Encephaloid grows more quickly, distributes itself more 
rapidly, and attains a more considerable bulk than any 
other form of cancer ; tumours of this nature often being as 
large as a man's head, or even exceeding that size. It also 
softens more rapidly than the other forms of cancer, because 
the cells which are the element on which softening especially 
depends, are here the predominating ingredient ; and for the 

* See Plate vi. fig. 7 a, 8 d. f See Plate i. fig. 11. 



ENCEPHALOID. 



319 



same reason it is the most likely to form a discharging ulcer, 
and the most rapid in assuming that condition. Hence of all 
forms of cancer encephaloid runs the quickest course, is the 
most malignant, and causes death in by far the shortest time. 
It often destroys life in a few weeks, or at furthest in a few 
months after its first appearance, unless it has been removed 
by an operation at an early stage. 

Encephaloid appears to occur primarily or secondarily in 
nearly every organ and portion of the body, at every age, and 
in both sexes. 

From the above observations it may be easily imagined 
that the coarser anatomical and physical relations of encepha- 
loid are extremely variable ; and this view is supported by 
experience. The colour of encephaloid tumours varies consi- 
derably ; they are sometimes whitish, sometimes of a yellow 
tint, sometimes almost gray, so that in the same case there 
are some parts that may very fairly be compared to the white, 
and others to the gray substance of the brain. In other cases, 
when the tumour is penetrated by numerous minute vessels, 
we have a reddish, flesh-coloured, or pink tint. When blood 
extravasated from the injured vessels has become mixed with 
the substance of the tumour, as usually happens at the com- 
mencement of softening, the whole mass, or certain portions 
of it appear of a dark red colour, or if the hsematin of the 
extravasated blood has begun to change, the tumour may 
present a brownish-red or mahogany tint. 

These tumours likewise differ in their consistence ; before 
softening they are firm, varying lrom the consistence of solid 
lard to that of the brain ; after opening they sometimes become 
more granular or fibrous, and sometimes as they soften, they 
cease to discharge, but on pressure are converted for the most 
part into a milky and apparently purulent fluid. In those cases, 
in which from the very first the consistence has been slight, if 
the tumour is deposited near the external surface, as under 
the skin, or in certain muscles, it frequently communicates a 



320 



PATHOLOGICAL EPIGENESES. 



deceptive feeling of fluctuation, before the commencement of 
softening. 

With regard to its anatomical arrangement in the mass, 
encephaloid sometimes forms only a single tumour, and some- 
times many ; and varies from the size of a hemp seed to that 
of a man's head. These tumours are usually blended with the 
surrounding parts (infiltrated encephaloid), but occasionally 
they are perfectly separated from the adjacent tissues, being 
enclosed in an indefinite capsule of areolar tissue, which 
sometimes exhibits the characters of cartilage (the combination 
with fibrous cancer) just as is generally observed in newly 
formed areolar tissue. Sometimes encephaloid occurs in small 
patches enclosed in fibrous partitions, presenting a certain 
resemblance to the normal structure of the pancreas (pan- 
creatic tumour). There are other varieties which are less 
striking to the eye, and which from the absence of any thing 
with which to compare them, have received no special names; 
they all, however, serve to elucidate the histological arrange- 
ment of encephaloid, and its relations to the parent-tissue. 
The latter is usually so concealed by the morbid deposit, that 
frequently even the most careful examination fails in detecting 
its elements. 

When encephaloid is developed in external parts of the 
body, as in the bones of the extremities, or the subcutaneous 
cellular tissue, it gradually becomes blended with the skin, 
which is thus rendered distended and cedematous, the superficial 
veins standing forth like blue cords. It finally ulcerates, and 
there are formed fungoid growths, irregular leafy and cauli- 
flower granulations, which are usually extremely vascular, and 
bleed on the slightest provocation (fungus nematodes) ; these 
granulations are not inclined to become organized; they 
unite, and discharge to such a degree, as rapidly to induce 
death by colliquation. 

The diagnosis of encephaloid is essentially characterized 
by the same signs as those of cancer generally. From scirrhus 



ENCEPHALOID. 



321 



it is distinguished by its greater softness, by its more rapid 
course, and by its small amount of fibrous tissue. There is, 
however, no strict line of demarcation between them ; and many 
very characteristic cases have been at first sight regarded as 
encephaloid, which after a more careful examination seemed 
doubtful, or to occupy a transition-form between the two. 
The accurate limitation of encephaloid, is rendered more dif- 
ficult by its combining with other forms of tumour, as with 
melanosis (cancer melanodes) or with telangiectasis. # This 
combination may probably occur in several ways ; the mela- 
nosis and the vascular structure may be superadded to the 
encephaloid, or conversely the encephaloid may be the last 
formed, or finally the two epigeneses may be simultaneous. 

There is also a species of false encephaloid, a morbid 
epigenesis which in its physical properties appears identical 
with true encephaloid, but in its histological and physiolo- 
gical relations is essentially different from it. I once observed 
a tumour of this nature in a lung ; it was of the size of a 
walnut, of a reddish-white tint, about as soft as brain, and 
was declared to be encephaloid by all the physicians who 
were present. When examined under the microscope it was 
found to be merely a deposition of oil-globules (fat) in the 
normal tissue of the lung, and hence there remained no doubt 
of its non-malignant nature.f This example may serve to 
show the possibility of such mistakes ; future carefully con- 
ducted histological investigations will probably lead to the 
discovery of other forms of tumour which may be mistaken 
for encephaloid. 

As instances of the coarser anatomical and physical, as well as of the 
histological relations of encephaloid, I may refer to the description (,f 
Plate vi. fig. 7 — 11. An instance of the transition-form merging into 
fibrous cancer, is given in the description of the case of cancer of the 
knee-joint represented in Plate vin. fig. 6 — 7. The following case will 

* See R. Froriep in the Encyclop. Worterbuch der medic. Wissen- 
schaft, vol. xiii. Berlin, 1835, art. Fungus, 
f See Plate vi. fig. 10, a, b. 

VOL. I. Y 



322 



PATHOLOGICAL EPIGENESES. 



serve to give a good idea of the mode in which encephaloid extends 
itself. A joiner about forty years of age, had for three years a swelling 
of the testicle which gradually enlarged. There was subsequently 
formed a tumour in the abdomen which was perfectly visible on a mere 
ocular examination. He died after having experienced paralysis of the 
lower extremities and the bladder. The left side of the scrotum was 
much enlarged, and on piercing its walls a considerable amount of a 
clear yellow fluid spirted out. A large portion of the tunica vagin. 
propria testis was attached to the albuginea by fresh adhesions, which 
admitted of ready separation by the finger. The testicle and epididy- 
mis of the left side were much enlarged, weighing fourteen ounces. 
They, however, retained their normal shape and exhibited, indepen- 
dently of the recent exudation, a smooth surface. They were both of a 
tolerably firm consistence, and their section exhibited a yellowish tint. 
Internally the mass was coarsely granular, resembling fresh curds. The 
cord traced from the testicle, exhibited minute knotty swellings before 
entering the abdominal ring. In the abdominal cavity these increased 
in frequency 'and size, and finally became fused together into a large 
encephaloid mass, the size of a child's head, covering the whole of the 
left side of the vertebral column as far as the diaphragm, enclosing, the 
aorta and the left kidney, but not extending into the right side of the 
abdominal cavity. It was of a white colour, resembling brain, was soft, 
and when pressed between the fingers, was easily reduced to a pulpy 
consistence. Histologically the soft encephaloid in the abdomen con- 
sisted of minute cells of the most varying forms, between which were 
very numerous fat-granules and oil-globules. In the testicle these cells 
were likewise found, but they were deposited in a firm amorpho- 
granular mass. 

The chemistry of encephaloid is in much the same condition 
as that of cancer generally. The analyses which have been hitherto 
published are either far behind the present state of science, or must 
be regarded merely as starting points for future chemists, and in 
their present state do not admit of the deduction of any general con- 
clusions. In the first category we may place the analyses communi- 
cated by Lobstein,* and those of Hauser,f and Baudrimont -,t in the 
latter those of Brande,§ Valentin, || J. Muller, and Scherer.^" Of the 
chemical nature of the principal ingredient of encephaloid — the cancer- 

* Lobstein, Anatomie pathologique, vol. i. 

f Oesterreichische medic. Jahrb. Marz, 1841, p. 31 7- 

+ L. Gmelin, Chemie, vol. ii. p. 1373. 

§ Berzelius, Lehrbuch der Chemie, 4th Ed. vol. ix. p. 729. 

H Repertorium, vol. u. p. 277. 

% Untersuchungen, p. 220, 221. 



ENCEPHALOID. 



323 



cells — we are altogether ignorant ; the other constituents are not so 
essential, and to a certain degree vicarious. As a general rule ence- 
phaloid contains much more fat than fibrous cancer. Cholesterin is 
often present, frequently occurring in softened encephaloid in the form 
of crystals. Whether the phosphorized fats discovered in encephaloid 
by some chemists (Brande, Beaudrimont) are of any especial impor- 
tance, must be determined by future investigation. J. Muller dis- 
tinguishes three varieties of encephaloid : 

1 . Encephaloid abounding in roundish cells, though intersected by a 
delicate fibrous net work. 

2. Encephaloid with an exceedingly soft cerebriform base, composed 
of pale elliptic corpuscles devoid of caudate appendages. 

3. Encephaloid with caudate or fusiform corpuscles. The latter he 
regards as cells in the process of conversion into fibres ; it seems to me, 
however, to be very doubtful, whether tumours consisting merely of 
fibre-cells should be regarded as encephaloid. Moreover, it is not 
always easy to determine whether the caudate cells must be regarded as 
always progressing into fibres,* or whether they should be viewed as 
peculiar encephaloid- cells incapable of further development. Glugef 
regards the caudate bodies described by Muller as an artificial product 
arising from the action of spirit. It is certainly true that encephaloid 
preserved in spirit is no longer fit for histological examination, and that 
albumen coagulated by alcohol may sometimes assume forms, which 
under the microscope present a remote similarity to elongated cells ; 
however, none who are used to microscopic investigations could mistake 
such artificial products for actual, unaltered cells, and Muller's experience 
in this department, as well as the figures of these cells, which he has 
depicted, utterly overthrow Gluge's supposition. Respecting the causes, 
mode of formation, and importance of encephaloid, we can merely 
apply the same observations as were previously made in relation to 
cancer generally. Some writers have endeavoured to establish an espe- 
cial connexion between encephaloid and nervous tissue, regarding the 
former as merely an abnormal development of the latter structure. Such 
opinions have not even a shade of probability : they are based on an 
accidental similarity existing between the two, in colour, consistence, 
and certain chemical constituents. The microscope at once reveals the 
essential difference between these structures. 

* See Plate viii. fig. 9. 

f Atlas der pathologischen Anatomie, Part 1, p. 19. 



Y 2 



324 



PATHOLOGICAL EPIGENESES. 



SECOND FORM. 

FIBROUS CANCER SCIRRHUS. 

Synon. Cancer scirrhosus ; carcinomatous sarcoma ; hard cancer ; car- 
cinoma simplex ; carcinoma fibrosum.* 

Under the term scirrhus we include those forms of cancer 
in which the fibrous tissue predominates, and which are 
consequently firmer and harder than encephaloid : hence its 
name.f In its early stages we find more frequently than in 
encephaloid, a firm, amorphous blastema; hence scirrhus 
does not invariably exhibit decided and perfectly formed 
fibres, for here as in the genuine fibrous tumours, the blas- 
tema does not always, even in the more advanced stages, 
undergo transformation into distinct fibres admitting of 
isolation, but sometimes permanently remains as an indefi- 
nite fibrous mass, holding a position both morphologically 
and chemically between coagulated fibrin and the gelatigenous 
fibrous tissue. The fibrous portions of scirrhus coincide in 
every point of view with those of non-malignant fibrous 
tumours, and hence, as we have already mentioned, scirrhus 
must be regarded as a combination of encephaloid with fibrous 
tumour. There are thus an endless number of transition- 
forms, the extremes of the series being on the one hand 
encephaloid, and on the other fibrous tumour. The mutual 
relations between the fibres and the cancer-cells vary ex- 
tremely in scirrhus; sometimes both elements occur with 
a certain degree of regularity, the fibres forming net- work or 
capsules, whose interstices and cavities are filled with cells, 
or else radiating from certain points ; sometimes on the other 

* See Miiller, op. cit. or West's translation; itannover, op. cit. 
p. 22, &c. ; Lobstein, Anatomie pathol. vol. i. ; and G. Gluge, Unter- 
suchungen, Part 1, p. 139, Part 2, p. 138. 

f aicippoQ, hard, firm. 



SCIRRHUS. 



325 



hand the fibres and cells are separated from each other. 
When, in the latter case, the tumour is divided into several 
portions, it is frequently impossible to distinguish some of 
these parts from encephaloid, and others from fibrous tumour. 
In scirrhus we frequently find the cellular structure less deve- 
loped than in encephaloid ; we rarely observe in it either large 
parent-cells, or cells with numerous cytoblasts ; more fre- 
quently the cells are small, roundish or oval, and granular. 
Elementary granules are common after softening has com- 
menced. Moreover, the viscid fluid is, as a general rule, pre- 
sent in scirrhus ; when it occurs in excess, it forms the tran- 
sition to gelatinous cancer. Since scirrhus is slower in its 
development, and more solid than encephaloid, so also is its 
action on the parent- tissues previously to softening more 
strongly marked; the elements of these tissues being more firmly 
compressed, become more readily atrophied. Hence, unsoftened 
scirrhus exhibits fewer and smaller vessels than encephaloid ; 
if they are not altogether absent, they are at all events very 
small, and may be easily overlooked by a careless observer. 
Large vessels in scirrhus are, however, not rare, and we 
frequently find the milk-ducts pervious in mammary scirrhus 
of long standing. 

Corresponding with these histological differences between 
scirrhus and encephaloid, there are also variations in their 
development, growth, and consequences. The growth of 
scirrhus is much the slower, for the cells on whose propaga- 
tive power the enlargement of encephaloid is chiefly dependant, 
are here of mere secondary importance ; hence scirrhus rarely 
attains to the same magnitude as encephaloid. On the other 
hand, the mechanical consequences of the tumour arising 
from pressure on nerves and vessels, contraction of canals, 
&c, are sooner and more energetically manifested than in 
encephaloid. 

Conversely the process of softening is slower in scirrhus, 
the cells forming minute radiating islets of pus, which 
do not become so easily converted into ichorous discharge, 



326 



PATHOLOGICAL EPIGENESES. 



but are more liable to resorption ; hence the softening is less 
likely to extend to the adjacent tissues. Consequently scir- 
rhus is much slower in conducing to a fatal result than ence- 
phaloid, and must be regarded as far less dangerous. While 
the latter often causes death in a few months, scirrhus usually 
continues for years. When the softening of scirrhus has 
progressed to a certain degree, there occur in it cavities, 
such as have been previously described, partially filled with a 
red ichorous fluid, and having fibrous or semi-cartilaginous 
walls united by irregular bands and arches. The granulations 
of scirrhous tumours resemble in all essential points those of 
encephaloid ; and in the later stages when open ulcers are 
once formed, the progress of scirrhus becomes more rapid, 
and more closely approximates to that of encephaloid. 

Scirrhus occurs as a secondary product in nearly every 
organ of the body, but its appearance as a primary affection 
is much rarer than that of encephaloid, and it seems for the 
most part to attack glandular organs. It appears most fre- 
quently during the latter half of life — from the fortieth year ; 
and does not attack children. Finally it is more common in 
the female than in the male sex, in consequence of the 
female breast being the most common seat of the affection. 

As there are great differences in the histological arrange- 
ment of scirrhus, so likewise are there extreme variations in 
the coarser anatomical relations of this form of tumour. 
Scirrhus usually forms a roundish tumour with a more or less 
nodulated surface. Its consistence is generally very firm ; 
the tumour in this respect resembling cartilage or even stone 
(cancer eburneus) ; this hardness depends on its fibrous struc- 
ture, and (as in the case of fibrous tumour) varies with the 
toughness, compactness, and amorphous character of the fibres. 
Its nodules, in cases where the tumour is superficial, are fre- 
quently observed, on the application of the hand, to be of a 
lower temperature than the surrounding parts. This is pro- 
bably dependant on the circumstance, that in consequence of 
the limited supply of blood to these parts, the metamorphosis 



SCIRRHUS. 



327 



of tissue is much checked ; however, I do not regard this 
hypothesis as a conclusive answer to the question. On 
passing a knife through them, scirrhous tumours craunch in 
just the same manner as fibrous tumours. 

A section of one of these tumours sometimes appears of a 
bluish-white or milky colour, transparent, opalescent and 
shining — characters dependant on the fibrous portion, and 
exhibited in like manner by fibrous tumours ; sometimes it 
presents a more opaque appearance, and is of a white or gray 
colour, with a shade of yellow — a character depending on the 
cells ; and occasionally it presents a reddish tint if many 
blood-vessels are present. In most cases the unaided eye will 
detect difference of structure at different points ; some parts 
being fibrous or transparent ; while others are opaque, yellow, 
or green ; when softening has commenced, a caseous appear- 
ance is sometimes presented. By scraping a tumour of this 
nature, we usually obtain a whitish creamy fluid. Specks of 
blood are rarely observed, and coagula never unless softening 
has advanced, and the blood-vessels are injured. As a general 
rule, scirrhus is intimately blended with the surrounding 
parts, not being enclosed in a capsule or presenting a definite 
border. 

In regard to the diagnosis, and pathologico-anatomical 
appearance of fully developed scirrhus, we have nothing further 
to add ; but even the most experienced observer, with every 
aid to diagnosis at his command, will frequently be in doubt, 
whether or not he is examining true scirrhus, since this form 
of cancer presents so many transitions into other sorts of 
tumours. These are, as we have already had occasion to 
nention. 

First, the transition into encephaloid. It often appears 
to be a point of indifference whether a tumour should be 
referred to encephaloid or to scirrhus; the cancer-cells, and 
the fibrous structures being so equally balanced, that neither 
element predominates. Sometimes again, one portion of a 
cancerous tumour resembles encephaloid, whilst another more 
close! v resembles scirrhus. These are cases belonging strictly 



328 



PATHOLOGICAL EPIGENESES. 



to neither encephaloid nor scirrhus, but embraced in one of 
the numerous forms of cancerous tumour, which do not find 
a place in our artificial arrangements, however much we may 
extend them. 

A second transition-form is that into gelatinous cancer, of 
which we shall speak presently. 

The third series of transition-forms are those into non- 
malignant fibrous tumours. These are of the highest patho- 
logical importance, and are more likely to occur in proportion 
as the scirrhus is removed from encephaloid. In tumours 
previous to softening, it is often impossible to distinguish 
whether the few cells observable amongst the fibres are cancer- 
cells, or whether they are the developmental cells of other 
tissues, and this is a point on which microscopic examination 
can throw little light. Even after the establishment of soften- 
ing, the diagnosis is sometimes uncertain, since non-malig- 
nant fibrous tumours may also undergo that change. It is 
a question which must be answered by future observers, 
whether in such cases cancer-cells are superadded as secondary 
formations to a fibrous tumour, originally non-malignant. 
I regard this secondary formation as not improbable, for we 
frequently observe that tumours which have existed for 
years without giving rise to more than mechanical annoy- 
ance, rapidly soften and become converted into cancer ; I 
have, in several cases, observed this to occur in fibrous tumours 
of the uterus and mammary gland. Hence many forms of 
scirrhus should be regarded as combinations of encephaloid 
with fibrous tumour, and I must express my conviction, that 
many cases which from their pathology and morbid anatomy 
have been termed scirrhus, have been merely epigeneses of 
fibrous tissue. Although Andral first called attention to it, 
yet almost daily we observe simple hypertrophy of the mus- 
cular or cellular coat of the intestinal canal, mistaken for 
scirrhus, — an error I have myself repeatedly witnessed. 

A further difficulty in the diagnosis arises when a cance- 
rous tumour consists for the most part of an amorphous solid 
cytoblastema. There are no means of distinguishing this 



SCIRRHUS. 



329 



from the solid cytoblastema of a non-malignant tumour, and 
a certain diagnosis can only be established when a portion of 
the tumour becomes characterized as more perfectly developed 
scirrhus. 

Hence it follows that the determination, whether a tumour 
is, or is not of a scirrhous nature, is sometimes, even with 
the best aids to diagnosis, merely presumptive, and occasion- 
ally the opposing characters are so equally balanced, that not 
even a conjectural opinion can be hazarded. 

A very characteristic form of scirrhus is exhibited in Plate viii. fig. 1, 
2 and 3 ; fig. 4 and 5 illustrate a case of cancer of the liver, which may 
be regarded as pertaining either to scirrhus or encephaloid ; fig. 6 and 7, 
exhibit soft cancer of the knee-joint, belonging more correctly to ence- 
phaloid than to scirrhus. Fig. 9, illustrates the formation of scirrhus 
from an amorphous cytoblastema. Other cases of scirrhus are illustrated 
in the second volume. 

Under the term carcinoma reticulare, J. Muller* describes a peculiar 
variety of cancer which must be here noticed. It embraces those 
forms in which accumulations of cancer-cells are deposited on the 
meshes of a fibrous stroma, so that a section of the tumour exhibits a 
more or less regular appearance of net- work. f The fibrous masses oc- 
cur in the form of thin transparent bands ; the accumulated cells are 
whitish ; but present a dark appearance when examined under the micros- 
cope by refracted light. The individual cells sometimes resemble the 
ordinary granular cells. Like the preceding forms of cancer ; it is not 
strictly defined, and hence it is not to be regarded as a peculiar spe- 
cies. 

Another form of cancer described by J. Muller, % under the term 
carcinoma fasciculatum seu hyalinum, appears histologically to be referable 
to this class, since it consists of very delicate fibres. It is, however, 
not firm like true fibrous cancer, but as soft as encephaloid, and highly 
vascular ; according to Muller, it contains no cancer-cells. Notwith- 
standing the great number of cancerous tumours which I have examined, 
I have never yet met with this variety ; hence my opinion with regard 
to the correctness of placing it in the above category must be considered 
only provisional. All that is known in relation to the chemistry and 
causes of scirrhus has been already given in our remarks on cancer 
generally. 

* Op. cit. p. 15, or West's translation, p. 44. 

f See Plate viii. fig. 10; also Muller, op, cit. Plate i. fig. 1 — 9, 

| Op. cit. p. 23, or West's translation, p. 66. 



330 



PATHOLOGICAL EPIGENESES. 



THIRD FORM. 

COMBINATION OF MELANOSIS AND CANCER. 

Melanotic Cancer. 
Synon. Cancer melanodes ; carcinoma melanodes.* 

We have already had occasion to mention that dark granu- 
lar pigment may occur as an incidental constituent of cance- 
rous tumours. This pigment is either enclosed in cells, which 
are only slightly, or not at all different externally from the 
ordinary cancer-cells (true melanosis), or it occurs in the 
form of free granules, and then sometimes consists of sulphuret 
of iron. Hence we have here the same differences as we for- 
merly noticed in our remarks on melanosis. 

The characters of melanotic cancer vary with the quantity 
and arrangement of the black pigment. When a small 
number of pigment-elements (cells or granules) are equally 
distributed over a large amount of cancerous structure, the 
tumour presents a gray colour. If an excess of pigment is 
deposited at special points, the cancer presents a dark 
speckled or marbled appearance. Finally if the amount of 
pigment is very excessive, the cancer presents throughout a 
blackish brown colour, and resembles in its appearance a true 
melanotic tumour. Melanosis is associated both with ence- 
phaloid and scirrhus ; the former, according to my own expe- 
rience, being combined with true, the latter with false mela- 
nosis. In its progress and relations melanotic cancer presents 
no especial peculiarities. 

FOURTH FORM. 

GELATINOUS CANCER, OR COLLOID. 

Synon. Cancer alveolaris ; carcinoma alveolare ; cancer areolaire ; 
cancer gelatiniforme.f 

We have previously described the viscid fluid, which forms 

* See Miiller, op. cit. p. 18, or West's translation, p. 55 ; Hannover, 
op. cit. p. 32. 

t See Miiller, op. cit. p. 16, or West's translation, p. 50; Hanno- 



COLLOID. 



331 



a tolerably constant, and, therefore probably essential ingre- 
dient of cancerous tumours. This gelatinous fluid is so 
increased in certain forms of soft cancer, as to give the 
tumour a very peculiar appearance. In some cases this jelly- 
like matter is enclosed in cellular cavities, varying from the 
size of a pin's head, to that of a wall-nut, or even of an egg : 
the cancerous tumour then presents a very characteristic 
appearance, and receives the name of gelatinous cancer, or 
colloid. The stroma of these tumours is invariably fibrous, 
being sometimes a delicate net-work, and in other cases being 
very thick, tough and apparently cartilaginous, such as occurs 
in fibrous cancer. In the interstices between these fibres, 
there lies this colourless, transparent jelly, which, when ex- 
amined under the microscope, is found either to retain its 
transparent and amorphous appearance, or else to enclose very 
pale cells,*' differing, however, from true cancer-cells, being 
generally speaking, larger and more delicate, and the walls 
not being so thick. Occasionally, we observe crystals of 
ammoniaco-magnesian phosphate enclosed in the gelatinous 
matter. No true softening or suppuration occurs in this form 
of cancer ; in the intestinal canal where it is most frequent, 
the surrounding tissues become gradually infiltrated by the 
jelly ; strictures are thus formed in the gut, and the contents 
of the canal being pressed on the soft gelatinous mass, give 
rise to perforation of the walls. Hence gelatinous cancer is 
in some degree different in its progress from the other forms 
of carcinoma. 

Regarding the causes of this variety of cancer nothing cer- 

ver, op. cit. p. 29 ; Otto's seltene Beobachtungen zur Anatomie, Phy- 
siologic, und Pathologic Plate i. fig. 4; Cruveilhier's Anatom. patholog. 
liv. 10, tab. 4 ; copied in Hope's Principles and Illustrations of Morbid 
Anatomy, fig. 180, 181 ; Carswell's Pathological Anatomy, fasc. 3, 
tab. 1, fig. 8; Broers, Observationes anat. patholog. Lugd. 1839, c. 4, 
tab.; G. Gluge's Untersuchungen, Part 1, p. 132. 
* See Plate viii. fig. 11. 



332 



PATHOLOGICAL EPIGENESES. 



tain is known. Muller believes that its gradual enlargement 
is dependant on a further development and increase of the 
cells containing the jelly ; young cells being formed within the 
parent- cells. 

Colloid, in its characteristic form, most commonly occurs 
in the intestinal canal between the stomach and the rectum, 
from whence it proceeds to the peritoneum — especially the 
omentum ; it more rarely occurs in other organs — in the breast 
bones, &c. 

The external characters of this form of cancer are so very 
striking, that no one who has once seen a case, or even a good 
plate of it, can well err in his diagnosis. The peculiar interstices 
formed by the fibrous meshes and filled with jelly, present no 
variation, at least in cases of fully developed colloid. When 
colloid presents transitions into other forms of cancer, as, for 
instance, when the jelly is not enclosed in its proper inter- 
stices, but is deposited free between the fibrous structures 
and the cells, the diagnosis can only be established by micro- 
chemical examination, and there is a difficulty in assigning to 
the tumour its proper place in the scale of cancerous forma- 
tions. 

The reader will find a description of several cases of colloid, with 
plates, in the chapter on the morbid anatomy of the stomach and kites - 
tinal canal, in the second volume. 



Many forms of tumour which have received special names 
from morbid anatomists and surgeons, do not, in a histolo- 
gical point of view, merit such a distinction. To this class 
belong polypi and fungoid growths. The former have 
only this in common — that they arise from, or are invested 
with mucous membrane. But if every epigenesis invested 
with mucous membrane, and developed in or under such a 
membrane, be termed a polypus, it is obvious that there may 
be great differences in the histological arrangement of such a 



UNORGANIZED PATHOLOGICAL EPIGENESES. 333 

class.* The nucleus of a polypus may, however, be formed 
by almost any form of tumour, either by a non-malignant 
structure — as lipoma, fibrous tumour, or encysted tumour ; or 
by a malignant structure — as carcinoma. The same is the 
case with fungoid growths, which may arise from any dis- 
charging tumour, ulcer, &c. We shall have more to say in 
relation to these tumours in the second volume. 



SPECIAL RELATIONS 

OF 

UNORGANIZED PATHOLOGICAL EPIGENESES. 

The unorganized epigeneses occurring in the human body 
are very numerous, and present many varieties. In the fol- 
lowing pages, devoted to their special consideration, we shall 
commence with certain general considerations, beginning with 
their elementary relations. 

All these forms arise from fluids — mother-liquids, holding 
the matter of which the future deposit is composed, in a state 
of chemical solution. Nearly every fluid in the body may act 
as a mother-liquid, since they all contain matter which, under 
certain conditions, may be separated in a solid form. The 
conditions for this separation are in all respects identical 
with those which chemistry teaches us to recognize in relation 
to the separation of solid bodies from their solutions, that is 
to say, the deposits invariably follow chemical laws. 

As a general rule, the separation of a substance from a 

* Regarding the histological relations of polypi, consult the treatise of 
Frerichs, de Polyporum Structura Penitiori. Leerse, 1843 ; and regarding 
the coarser relations, see Meissner fiber die Polypen in verschiedenen 
Hohlen des menschlichen Korpers, Leipz. 1820. 



334 



PATHOLOGICAL EPIGENESES. 



fluid takes place when the conditions on which its solution 
depends, are checked. The causes which may hinder it from 
remaining dissolved are various ; they may, however, for con- 
venience, be arranged in the two following classes : 

1 . The dissolved substance may undergo a chemical change 
so as to become altogether, or in a great measure, insoluble in 
the fluid in which it was previously dissolved. Cases of this 
nature are remarkably numerous, and occur under a variety of 
circumstances. Thus, for instance, bicarbonate of lime dis- 
solves in water, but if it becomes converted into the neutral 
carbonate it is no longer soluble, and becomes deposited. At 
the temperature of the human body, urate of ammonia and 
the other uric-acid salts are soluble to a certain extent in 
w T ater ; if, however, they are decomposed by the addition 
of an acid, the uric acid becomes liberated, and being 
much more insoluble than the majority of its salts, forms 
a deposit in the fluid. If oxalic acid is mixed with an 
aqueous fluid containing a soluble salt of lime, oxalate of lime 
is formed, which, being insoluble in water, separates as a 
deposit. 

Another cause, closely allied to the preceding, is a change 
in the solvent fluid. Phosphate of lime, for instance, is 
soluble in acid, but not in alkaline fluids ; hence, if an acid 
solution of this salt should in any way become alkaline, a 
precipitation takes place. Another view may, however, be 
taken of this process ; it may be supposed that phosphate 
of lime in an acid fluid becomes converted into a super- 
phosphate — the free acid taking up a part of the base from 
the neutral salt of lime — and that the super-salt is soluble 
in water: and that the alkaline fluid, on the other hand, 
removes a portion of the acid from the lime and forms a basic 
salt insoluble in water. Hence, taking this view of the ques- 
tion, the two causes are in reality identical. 

2. All substances soluble in aqueous fluids are merely so to 
a certain extent, that is to say, a certain amount of water is 



UNORGANIZED PATHOLOGICAL EPIGENESES. 335 

requisite in order to retain a certain amount of the substance 
in solution. The solution is then saturated. If a portion of 
water is removed, a corresponding amount of the substance 
must separate in an undissolved form. 

Both of the above cases occur in the human body, and 
give rise to numerous separations of matters no longer soluble 
— precipitates. The former cause is frequently in operation, 
and acts under very different conditions, as we shall perceive 
when speaking of the different forms of precipitate. The 
second cause is comparatively rarer, and depends for the most 
part on evaporation and endosmosis. 

By evaporation, a concentrated fluid occurring in a part of 
the body exposed to such an influence, may lose so much 
water that a part of the matter dissolved in it (or, indeed, the 
whole amount) may separate in a more or less solid form. 
This cause is very frequently in operation in the nasal cavity, 
more rarely in the mouth, the cutaneous glands, the vagina, 
behind the glans penis, and possibly also (although very rarely) 
in the lungs and bronchial glands. It is probably never 
effectual in parts more remote from an exposed evaporating 
surface. 

Endosmosis, as is well known, occurs when two fluids of 
unequal concentration are separated from each other by a thin 
animal membrane ; an interchange of their constituents taking 
place under these circumstances, and the thinner fluid becom- 
ing more concentrated. When a thin fluid of this sort is 
saturated with substances requiring a large amount of water for 
their solution — as, for instance, the urates — then if endosmosis 
comes in play, they no longer remain entirely dissolved, but a 
portion becomes separated. This view is, however, rather 
founded on general theoretical considerations than on special 
experiments, and requires further proof. 

Precipitates separated by either of the above causes may, 
as can be readily conceived, disappear, if conditions arise 
which render them again soluble. 

Precipitates are the commencement of all unorganized 



336 



PATHOLOGICAL EPIGENESES. 



pathological epigeneses. They bear the same relation to per- 
fectly formed concretions as the elements of the tissues to 
tumours. They frequently occur in such small quantities as 
entirely to escape detection by the naked eye; the microscope is 
then requisite to detect their presence, and to elucidate their 
formative relations. 

From microscopic investigation we learn that precipitates 
occur in three different forms — the amorphous, the indefinitely 
granular, and the crystalline. 

Amorphous precipitates form a transparent, gelatinous 
mass, difficult to observe under the microscope — as, for 
instance, basic phosphate of lime, or silica in the gelatinous 
state. 

Granular precipitates consist of very minute granules of 
indefinite size and form (generally roundish), in all respects 
identical with the elementary or molecular granules already 
described. Minute accumulations of them are generally 
colourless ; in large patches they appear dark when viewed by 
refracted, and white by reflected light ; we may instance 
albumen precipitated by an acid, or granular depositions of 
fat. In some few cases they present a coloured appearance ; 
thus the finely-granular deposits of urate of ammonia fre- 
quently present a brownish red, and sometimes a beautiful 
pink colour. 

Cry stalline precipitates consist of more or less perfectly 
formed crystals, which, however, are usually only microscopic. 
Many of the forms occurring in these precipitates are very 
characteristic, as, for instance, those of uric acid, ammoniaco- 
magnesian phosphate, cholesterin, andmargarin. Others are 
less perfect, or so minute that their crystalline form cannot be 
recognized under the highest powers. 

These three forms of precipitates are, however, not strictly 
separated from one another ; and it frequently depends upon 
accidental circumstances whether a precipitate assume one or 
other of them. The amorphous is generally the primary 
condition of the precipitate ; it subsequently assumes the gra- 



PRECIPITATES OF PROTEIN-COMPOUNDS. 337 



nular or crystalline state. In just the same manner as an 
amorphous cytoblastema becomes metamorphosed into a 
cell, which again undergoes a higher transformation and 
becomes converted into an integral constituent of tissue, so 
can an amorphous precipitate become converted into one of 
a granular character, and this again assume a crystalline form. 
This progressive metamorphosis does not, however, always 
occur. Many precipitates, as for instance, the protein-com- 
pounds, are incapable of crystallization, never being able to 
advance beyond the finely-granular state. On the other hand, 
crystals may be formed directly from a fluid, without previously 
assuming the amorphous or granular state. Chemistry 
teaches us that precipitates assume the crystalline form with a 
facility proportional to the slowness of their formation, and, on 
the other hand, that in proportion to the rapidity with which 
they are formed, they assume the amorphous or granular state. 
This law holds good in the same manner in relation to analo- 
gous morbid formations. 

Hence, as a general rule, it matters little whether a preci- 
pitate be amorphous, finely-granular, or crystalline ; and the 
occurrence of crystals in the human organism is usually not 
of that importance which many have attributed to it. 
With the exception of some few cases, as, for instance, the 
crystals in the inner ear (otolithes) it is only of importance in 
indicating the pre-existence of certain formative processes, or 
in enabling us to recognize, from the form of the crystal, the 
chemical composition of the substance composing it. 

We shall now consider the individual substances which 
occur as constituents of the precipitates in the human 
organism, their form, chemical relations, and mode of 
formation. 

1. Protein-compounds. We have nothing to add to the 
observations already made (see page 64) regarding fibrin 
coagulating in the amorphous state. It cannot be doubted 
that the protein-compounds often separate in a granular form, 

VOL. i. z 



338 



PATHOLOGICAL EPIGENESES. 



and constitute the elementary granules which have been 
so frequently mentioned. But the special relations of the 
individual protein-compounds, their metamorphoses, and the 
different degrees of solubility of their modifications are still im- 
perfectly known, and must be left for future investigators to 
work out. 

As a general rule, precipitates formed from protein may be 
recognized by the following characteristics : they are never 
crystalline, usually finely-granular, occasionally amorphous ; 
when treated with an aqueous solution of iodine, they assume 
a yellow colour ; they are insoluble in ether and mineral acids ; 
acetic acid renders them transparent without entirely dissolving 
them ; by prolonged action they dissolve in caustic potash ; 
when they can be isolated and obtained in large quantity, they 
dissolve by prolonged ebullition in concentrated hydrochloric 
acid, yielding a lilac-coloured fluid. When a finely-granular 
precipitate simultaneously presents all these reactions, it may be 
declared with certainty to be a protein-compound. If only 
a few of these reactions are exhibited, the diagnosis becomes 
comparatively less certain. 

The causes of the formation of these precipitates are still 
very obscure. We do not know, whether in individual cases, 
they consist of fibrin, albumen, or globulin, if we except 
those instances in which the fibrin coagulates in an amor- 
phous state ; and we are equally ignorant regarding the causes 
giving rise to the precipitation. Albumen, as is well known, 
is precipitated by the mineral acids, by heat, by alcohol, and 
by metallic salts — as, for instance, corrosive sublimate : the 
precipitates caused by these influences are likewise amorpho- 
granular : but it is extremely seldom that albumen is precipi- 
tated within the organism from any of the above causes. 
Other modes of explanation more closely approximate to the 
truth. Thus a modification of albumen has been lately recog- 
nized, which is precipitable by acetic acid, and another which 
is thrown down on the simple addition of water. It is pro- 



PRECIPITATES OF FAT. 



339 



bably of these and similar (still unknown) modifications of 
protein that these precipitates are formed. A wide and 
fruitful field for investigation is here open before us. 

It has been already mentioned that Lehmann referred certain granular 
precipitates insoluble in caustic potash, to the protein- compounds. I 
must here remark, that after repeated examinations, I still regard the 
existence of these protein-granules as very doubtful. In all the cases in 
which I have met with molecular granules insoluble in caustic potash, I 
have found, on continuing my examination, that they were perfectly 
soluble in ether, and therefore consisted of fat. 

Whether other organic substances occurring in the human 
organism, as ptyalin, pepsin, extractive matters, &c, form 
constituents of precipitates, must for the present remain unde- 
cided ; the probability is that (with the possible exception of 
pepsin) they do not, since, under ordinary circumstances, they 
are readily soluble in aqueous fluids. 

2. The fats very often occur as constituents of precipitates. 
The forms in which they present themselves differ with their 
chemical composition ; thus some form very characteristic 
crystals, whilst others are amorpho-granular. 

The following are the fats requiring especial consideration : 

a. Cholesterin, which frequently occurs in a crystalline 
state, and then forms very characteristic rhomboid tablets, 
with angles of 80° and 100°. # These crystals are insoluble in 
water, acids, and alkalies, but dissolve in ether and hot 
alcohol. We have no certain knowledge regarding the causes 
of the separation of cholesterin ; indeed, we do not even know 
how this substance, which in the normal condition occurs in 
small quantity in the blood, and many other animal fluids, 
and in larger quantity in the brain and nerves, is retained in 
solution. It probably exists in some still unknown combi- 

* See Plate x. fig. 1. The numbers given in the text are the mean 
of twenty admeasurements made by me with the camera lucida. The 
individual admeasurements of the acute angle, varied from 78° to 83°, 
which affords sufficient evidence of the accuracy with which crystals may 
be measured in this way. 

z 2 



340 



PATHOLOGICAL EPIGENESES. 



nation which renders it soluble, and whose gradual decompo- 
sition gives rise to its separation in a crystalline state. 
Cholesterin separates in large masses during the period of* old 
age ; and, in this point of view, the statement of Becquerel 
and Rodier, # that from the 40 — 50th year the amount of 
cholesterin increases in the blood of both sexes is very inte- 
resting. The augmentation of this substance in the blood is 
probably connected with an increased separation of it in the 
various parts of the body. A similar increase may, how- 
ever, take place in young persons in consequence of a morbid 
process. 

b. Margarin and margaric acid. These are crystallizable, 
forming very characteristic shapes, similar in both cases. 
They form microscopic needles which rarely occur alone, but 
usually in stellar or tuft-like groups.f They are most com- 
monly devoid of colour, but sometimes, when occurring in 
large masses, appear of a dark brownish tint, when viewed by 
refracted light. The crystals both of margarin and margaric 
acid are insoluble in water and in acids, but dissolve readily in 
ether and hot alcohol, and, after prolonged ebullition, in the 
caustic alkalies. 

Crystals of margaric acid may be distinguished chemically 
from those of margarin, by the circumstance that the former 
dissolve when boiled in weak spirit, while the latter require 
strong alcohol for their solution. 

The formation of crystals of margarin may be explained in 
the following manner. Human fat, as it occurs in adipose 
tissue, consists of an admixture of olein and margarin in 
indefinite and extremely varying proportions. The margarin, 
which at the ordinary temperature of the body is solid, is 
held in solution in the fluid olein, which naturally has a greater 
solvent power at a high than at a low temperature. Now, 
when this fat at the temperature of the human body is nearly 

* Comptes rendus, 1844, n. p. 1083. 
t Plate x. fig. 3. 



PRECIPITATES OF FAT. 



341 



saturated with margarin, it follows, that on cooling, a portion 
of the margarin separates in the crystalline form. Hence 
crystals of margarin are chiefly (if not exclusively) found after 
death, when the body has become cold. When human fat 
contains only a little margarin, then of course these crystals 
do not present themselves on cooling. Their occurrence must 
be regarded as forming the exception rather than the rule. 

Crystals of margaric acid are most commonly found in 
gangrenous parts, and appear to be a product of the decom- 
position of the margarin of the fat. The actual cause of this 
decomposition is still unknown, but may probably be traced 
to the presence of a free acid, which is frequently observed in 
gangrene. 

c. Olein at the ordinary temperature of the body is fluid, 
and separates in drops of all sizes (fat-globules), the larger 
of which are characterized by the peculiar manner in which 
they refract light. They occur partly free in the liquids of 
the body, and partly enclosed in cells. # These globules are 
insoluble in water and in acids, but dissolve readily in ether 
and hot alcohol, and, after prolonged ebullition, in potash. 
The behaviour of oleic acid (a rare constituent of the human 
body) is precisely similar. It is seldom that these fat- 
globules consist of pure olein or oleic acid ; they most com- 
monly contain a portion of solid fat in solution. 

The causes influencing the formation of these fat- globules 
are not always clear. In general this is the original form of 
olein — that in which, when it enters the body in large 
quantity, it proceeds from the food into the chyle. Sub- 
sequently, however, it appears to undergo changes, and 
to enter into combinations by which it passes into a state of 
solution. These combinations being destroyed, the olein 
again appears in the form of independent drops. Sometimes 
the free fat-globules proceed from the destruction of fatty 

* See Plate i. fig. 9 ; Plate in. fig. 16 ; Plate v. fig. 1, b, fig, 4* ; 
Plate vi. fig. 10 a ; Plate vn. fig. 1 c. 



342 



PATHOLOGICAL EPIGENESES. 



tissue in which fluid fat is enclosed in fat-cells — as, 
for instance, in gangrene, in the softening of tumours, 
and in suppuration occurring in parts abounding in fatty 
tissue. 

d. Moreover fat is often separated in a granular state, as 
fat-granules, to which some have incorrectly applied the term 
stearin-granules, for stearin in appreciable quantity does not 
exist in the human body. The fat in this condition usually 
occurs in molecular granules of indefinite form and size, their 
diameter rarely exceeding the 1000th or 800th of a line.* 
These granules are insoluble in water, acids, and cold caustic 
potash, but dissolve in ether and hot alcohol. Of what fats 
they consist we are still just as ignorant as we are regarding 
the causes leading to their formation and separation. It is 
possible, and indeed probable, that the serolin of the blood, 
which is uncrystallizable, and solid at ordinary temperatures, 
takes a share in their formation. 

In addition to the fats that we have named, it is probable 
that others are sometimes separated, as, for instance, the fats 
containing phosphorus, and the fatty acids of the nervous 
system (Fremy's cerebric acid) ; nothing is, however, yet 
known with certainty on these points. 

3. Uric acid and the urates. When uric acid occurs in 
deposits, we usually find it in the crystalline state. The 
primary form of its crystals is the rhombic prism, which fre- 
quently appears cut down to a tablet^ whose principal surfaces 
are rhombs. The crystals are not unfrequently united in 
masses with the form of rosettes.f The crystals, which, when 
perfectly pure, are colourless, often present a reddish tint ; 
they are insoluble in alcohol, ether, and acids ; nearly so in 
water, and only dissolve slowly in caustic potash. Crystals 

* See Plate in. fig 1 and 7 b ; Plate iv. fig. 1 a ; Plate viii. fig. 1,4 
and 6 ; Plate ix. fig. 1 and 4. 

f The most striking forms of uric-acid crystals are depicted in Simon's 
Animal Chemistry, Plate n. fig. 23. 



PRECIPITATES OF URIC ACID. 



343 



of uric acid have hitherto only been found in the urine. For 
the causes giving rise to their formation, we must refer to our 
observations on urinary calculi. 

Of the various salts of uric acid, the urate of am- 
monia demands the fullest consideration. It never occurs 
in the crystalline form, but always as a finely granular 
precipitate, * whose granules are sometimes connected by a 
tenacious membranous substance. These precipitates are 
scarcely ever colourless ; they present every shade, from a clay 
or yellowish red tint, to a brownish red or bright rose colour. 
They are only slightly soluble in cold water, but dissolve more 
readily on the application of heat, and separate again from 
the hot saturated solution on cooling. They are insoluble in 
alcohol and ether ; acids decompose them, liberating the uric 
acid — a circumstance which greatly aids their diagnosis under 
the microscope ; for on adding an excess of acid to a precipi- 
tate of this nature under the microscope, the granules gra- 
dually disappear, and are replaced by rhombic tablets of uric 
acid.f Urate of ammonia existing in the sedimentary form 
has hitherto been found only in the urine : we shall, there- 
fore, postpone our observations on its mode of formation 
till we speak of urinary calculi. 

The urate of soda is likewise found in a separated condi- 
tion in the human body, occurring in many of the gouty 
concretions of which we shall presently speak. 

For certain other sediments which occur solely in the urine 
(as those of cystin, uric oxide, &c.) , we must refer to our obser- 
vations on urinary calculi. 

4. Salts of lime. The following insoluble calcareous salts 
are of frequent occurrence as constituents of precipitates in 
the human organism. 

a. Oxalate of lime forms octohedric crystals, inso- 
luble in water, alcohol, ether, and acetic acid, but soluble in 

* See Simon, op. cit. fig. 28 a. 
t See Simon, op. cit. fig. 28 c. 



344 



PATHOLOGICAL EPIGENESES. 



hydrochloric acid. They are sometimes so minute that it is 
impossible to recognize their crystalline form, and they pre- 
sent the character of a granular precipitate. They have 
hitherto been only observed in the urine. 

b. Basic phosphate of lime. (8 Ca 0 + 3 PO g according 
to Berzelius) forms, when recently precipitated an amor- 
phous, transparent, colourless jelly, scarcely visible under 
the microscope, but gradually becomes converted into an 
indefinite granular mass. It is insoluble in water, ether, 
alcohol, and alkalies, but dissolves in acids without effer- 
vescing. 

Phosphate of lime forms a common precipitate in nearly 
every animal fluid. In the normal condition of the body, it 
is either held in solution by an acid, or forms soluble com- 
pounds with certain organic matters, as protein-compounds, 
gelatin, (?) &c, a class of combinations which have not yet 
been sufficiently studied. If a compound of this nature is 
decomposed, and the phosphate of lime meets with nothing 
to redissolve it, it separates as a precipitate. 

Whether neutral phosphate of lime occurs as a precipitate 
in the human organism is unknown. 

c. Carbonate of lime occurs both as an indefinite granular 
precipitate, and as a crystalline mass. Perfect rhombohedric 
crystals of this substance have not yet been observed in the 
human organism, but have been frequently noticed in animals 
and plants. They are insoluble in water, ether, alcohol and 
the alkalies, but dissolve with effervescence in acids — reactions 
which, when observed under the microscope, are sufficiently 
characteristic. 

Precipitates of carbonate of lime occur in almost every 
fluid of the body. How they arise is a purely conjectural 
point. Either the salt exists in the animal fluids as bicarbo- 
nate, and becomes precipitated when by the abstraction of 
carbonic acid, it is reduced to the state of the simple carbonate, 
or calcareous salts soluble in the animal fluids (as the oleate, or 
lactate of lime, or chloride of calcium) on meeting with the 



PRECIPITATES OF AMMONIACO-MAGNESIAN PHOSPHATE. 345 

free carbonic acid which pervades all the usual juices, become 
decomposed, and form carbonate of lime. 

Sulphate of lime is probably an occasional constituent of 
precipitates ; it has, however, not yet been observed. 

5. Ammoniaco-magnesian phosphate is crystalline; its 
form, however, varies in accordance with the rapidity with 
which its crystals are produced. If formed quickly we have 
stellar groups consisting of acicular crystals, or leafy aggre- 
gations presenting a great similarity to the indented leaves of 
the leontodon taraxicum.* The crystals, when slowly pro- 
duced, have a very characteristic form ; their regular appear- 
ance being that of a three-sided prism, in which the angles 
at the extremities of one margin are truncated by planes pass- 
ing through the opposite angles at either end. Sometimes 
other corresponding angles are also truncated, as in fig. 4 b 
and c of Plate x.f 

It is not easy to explain the causes of the numerous deviations in 
form, which these crystals present, and to reduce them to their common 
primary form, which appears to be the rhombic prism. J 

Crystals of ammoniaco-magnesian phosphate are insoluble 
in water, alcohol, ether, and alkalies, but dissolve readily, and 
without effervescence in acetic and the mineral acids. This 
chemical reaction, combined with their characteristic crystal- 
line form, renders their diagnosis sufficiently easy. The former 
and less decided crystalline form of precipitate, generally 
speaking, only occurs when ammonia is added to the animal 
fluids, and a rapid precipitate is thus induced. Precipitates 
formed naturally within the body appear, as far as my expe- 
rience goes, to consist invariably of the latter and more perfect 
form of crystals. 

* See Simon, op. cit. fig. 30, where, however, most of the crystals 
exhibit a more perfect form. 

t See Plate x. fig. 4 a, or Simon, op. cit. fig. 27. 
+ See the description of Plate x. fig. 4. 



346 



PATHOLOGICAL EPIGENESES. 



The formation of this precipitate is easily explained: all 
the fluids of the animal body contain, as a general rule, 
phosphate of magnesia, and if ammonia is brought in contact 
with this salt, crystals of ammoniaco-magnesian phosphate are 
produced. Hence it is that these crystals are amongst the 
most common that are met with in the microscopic examina- 
tion of the human body. In the dead body, in which 
ammonia is developed as a product of decomposition, all the 
tissues, as well as all the fluids, are often filled with them. 
Moreover, on examining under the microscope almost any 
animal fluid to which ammonia has been added, we observe 
groups of crystals of the first form. 

6. Sulphur et of iron, when it occurs in large patches, 
appears to the naked eye as a black, dark blue, or blackish- 
green deposit. Under the microscope we observe it as a gra- 
nular precipitate, whose granules vary from mere molecules 
to the 400th of a line in diameter. It is insoluble in water, 
but dissolves in acids ; on treating an acid solution with 
hydrosulphate of ammonia, a black precipitate is again formed. 

The manner in which this precipitate is formed has been 
already (see page 195) explained. 

7. Bile-pigment (the cholepyrrhin of Berzelius, the bili- 
phcein of Simon) appears as a finely-granular precipitate 
(sparingly interspersed with minute microscopic crystals) of a 
yellowish-brown, very fiery colour, # insoluble in water and 
in most acids. Nitric acid changes its colour in a very 
characteristic manner ; first into a green, then into a blue and 
a red tint, and finally decolorizes it entirely. As a general rule, 
it only occurs in the bile. We shall return to the subject in 
our remarks on gall-stones. 

8. Silica undoubtedly occurs as a precipitate in the animal 
fluids, but only in such small quantities that it has not hitherto 
been detected by the microscope. 



* See Plate x. fig. 5. 



VARIOUS PRECIPITATES. 



347 



9. Precipitates may be formed of substances which are 
readily soluble in the animal fluids, and are only separated by 
concentration or evaporation of the liquids in which they are 
dissolved. 

To this class belong, in addition to many organic sub- 
stances, most of the salts with alkaline bases, as chloride of 
sodium, the phosphates and sulphates of soda and potash, &c. 
These precipitates form amorphous, granular, or crystalline 
masses, in accordance with their chemical properties and the 
time occupied in their separation. They invariably appear, 
when we examine, under the microscope, fluids which have 
been exposed to the influence of evaporation ; but these are 
mere artificial products, and do not require to be considered in 
this place. It would be very desirable if our knowledge of these 
crystalline forms were more accurate, as it would materially 
assist us in the chemical examination of the animal fluids. 

The question now arises : Do such precipitates occur in the 
living body in consequence of concentration of the fluids ? 
There are cases in which this certainly appears to occur. 
Thus, after the internal use of sulphate of magnesia as a 
purgative, I have observed microscopic crystals of this salt in the 
liquid evacuations ; and probably other purgative salts appear 
in the faeces in a similar manner. This is, however, a point 
of little importance in relation to pathological anatomy. 

On the other hand, it has been recently stated by F. Boudet, # 
that in concretions containing phosphate and carbonate of 
lime, there is also a large quantity of salts readily soluble in 
water (chloride of sodium, sulphate and phosphate of soda). 
If this is really the case, it is a very interesting fact, since it 
appears extremely remarkable that such salts do not, in a very 
short time dissolve, and thus disappear in the fluids moistening 
and surrounding them, which are not saturated, and further, 
are continuously being modified by endosmosis. Hence 
I think that Boudet's statement requires further confir- 



* Journal de Pharmacie et de Chimie, Nov. 1844, p. 335, &c. 



348 



PATHOLOGICAL EPIGENESES. 



mation before it can be regarded as expressing an undoubted 
fact. 

These are the substances which have been hitherto regarded 
as the constituents of the precipitates occurring in the human 
body. Further investigation will probably lead to a consider- 
able extension of the above list. 

From these precipitates, which are frequently invisible to 
the naked eye, and which, to be correctly observed in their 
various relations, require a microscopic examination, there are 
formed large concrements or concretions in a manner differing 
in individual cases, and not always very obvious. 

The various concretions may be arranged into two large 
groups : 

1 . Such as arise in the fluid secretions of the body ; and, 

2. Such as are formed in the parenchyma of organs. 

FIRST CLASS. 

CONCRETIONS IN THE FLUID SECRETIONS. 

These are invariably formed from the above-mentioned pre- 
cipitates, but the mode of formation varies. They may arise 
in any or all of the following ways : 

1. From an amorphous or crystalline precipitate there may 
be formed a tenacious crystalline mass — a concretion ; the same 
process taking place on a large scale, as on a smaller scale 
influences the conversion of an amorphous into a crystalline 
precipitate. 

2. A portion of a loose, disconnected precipitate, may be 
held together by mucus or some other connecting medium. 

3. The precipitate may attach itself to a foreign body in 
just the same manner as crystals deposit themselves around 
such a body inserted in a saline fluid, forming an incrusta- 
tion. In fact, there are two ways in which a foreign body 
exerts an influence in the formation of a concretion; one 
being, that it frequently excites a disposition in a fluid to form 
a precipitate. Thus, for instance, by exciting inflammatory 



CONCRETIONS. 



349 



irritation, it may give rise to the secretion of a too alkaline 
state of the serum, or of pus, which on their part produce a 
precipitation of the earthy phosphates held in solution in an 
acid fluid, as, for instance, the urine. The other manner in 
which a foreign body acts, is by its causing a precipitate which, 
without it, would have been discharged, to collect around it, 
and thus form a concretion. Pessaries act in this manner in 
the vagina ; and foreign bodies, in the nasal cavity and intes- 
tinal canal. They first become encrusted, and ultimately form 
the nucleus of a concretion. 

In one of these three ways the nucleus of the concretion 
becomes formed, and as precipitates are continually being de- 
posited around the nucleus, the concretion gradually increases. 
The augmentation proceeds either by layers, or in another 
manner. The mode of increase, and the consequent texture 
of the concretion, depend on the character of the deposits : 
if they consist of large pieces or crystals, the concrement is 
uneven and angular; if, on the other hand, the deposit 
consists of fine granules, it is regularly laminated and 
smooth. Hence the external form of concretions presents 
many varieties ; generally it is round, but if several are simul- 
taneously present, and they are at all soft, as, for instance, is the 
case with most gall-stones, their mutual pressure and friction 
render their form polyhedric. Their shape also depends on 
that of the organ in which they are formed ; if it is a narrow 
canal, the concretion is elongated, acicular, or sausage-like ; if 
it is of an irregular form, so also is the concretion ; in cavities 
dividing into branches, as, for instance, in the pelvis of the 
kidney, the concretions have frequently a ramifying form. 
These relations are too obvious to require further comment. 

When these concretions are large, they receive the name of 
calculi, or stones ; when they are minute and numerous, they 
are termed sand, or gravel. 

We now proceed to the consideration of the various sorts 
of concretions. 



350 



PATHOLOGICAL EPIGENESES. 



1. URINARY CALCULI. 

To this class belong all concretions whose mother-liquid is 
the urine. They may be formed in any part of the urinary 
apparatus ; their most common seats of formation are, how- 
ever, the kidneys and bladder, and we consequently distinguish 
renal and vesical calculi. Calculi found in the ureters and 
the urethra are usually not formed there, but in the kidneys or 
bladder, and getting into those canals, become impacted there. 
It has happened, after injury to the urinary organs, that 
calculi have formed in the adjacent tissues into which there 
has been infiltration of urine. 

According to the above terminology we distinguish between 
urinary calculi, and urinary gravel or sand. Under the latter 
denomination we include the innumerable minute concretions 
which are so small that they can be discharged through the 
urethra without pain. 

Urinary calculi present great differences, not merely in their 
physical characters — as form, size, hardness, and colour — but 
also in their chemical constitution and in the relations inducing 
their formation. They sometimes consist of the same che- 
mical ingredient throughout, sometimes of a mixture of several 
substances ; hence they are simple and compound. 

We shall first consider those which contain only a single 
ingredient : # 

1. Calculi of uric acid and urates are the most common of 
all urinary concretions, but, according to the substances of 
which they are composed, they present many varieties. 

* The literature of urinary calculi is very copious. A list of the older 
writers would occupy too much space. Of the more recent authors 
we may especially mention : Berzelius in his Lehrbuch der Che- 
mie, translated into German by Wohler, vol. ix. 4th Ed. p. 486, &c. ; 
Scharling de Chemicis calculorum rationibus, Havniae, .1839; or Dr. 
Hoskin's English translation, London, 1 842 ; and Taylor's Catalogue of 
the Calculi in the Royal College of Surgeons, London. 



URINARY CALCULI. 



351 



Calculi of uric acid are very frequent, and often attain a 
considerable size. It is very seldom that the uric acid is per- 
fectly pure, and that the calculi are white ; it is most com- 
monly associated with the colouring matters of the urine, 
which communicates to such concretions a yellow, red, or 
reddish-brown tint. They are sometimes smooth, sometimes 
(but more rarely) verrucose, and frequently consist of regular 
lamina?. They almost always contain minute quantities of 
other ingredients. 

This species of calculus is very easily recognized by the charac- 
teristic reaction of uric acid ; on dissolving it in nitric acid, with 
the aid of a gentle heat, evaporating nearly to dryness, and 
then adding a little ammonia, a very beautiful purple colour is 
evolved. Beginners may easily commit the error of exposing 
the nitric- acid solution to too powerful a heat, in which case 
the expected reaction does not occur. This is best avoided 
by adopting Jacobson's plan of gently warming a minute por- 
tion of the stone — not larger than a mustard-seed — in a 
watch-glass, with a couple of drops of nitric acid, till by 
evaporation the solution forms a thick fluid mass ; this must 
now be inverted over a second watch-glass containing a few 
drops of caustic ammonia. The vapour of the ammonia will 
saturate the nitric acid, and the red colour will appear. 

This reaction occurs equally whether the stone consists of 
pure uric acid or of urates. We now proceed to explain how 
the latter may be recognized. 

Calculi consisting entirely, or for the most part, of urate of 
ammonia, are rare, and usually small. They are seldom white, 
being more commonly of a clay or yellowish-red colour. 
Their surface is smooth, or studded with minute warts ; on 
making a fracture, they appear earthy or laminated. 

The first step in the recognition of urate of ammonia is 
afforded by the characteristic reaction of the uric acid, from 
which, however, it may be distinguished by the following 
means : 

Uric acid is almost insoluble in water, while urate of am- 



352 



PATHOLOGICAL EPIGENESES. 



monia dissolves in hot water to a very considerable extent. 
We, therefore, boil a little of the pulverized calculus in 
water, and filter the saturated solution while still hot. On 
cooling, a portion of the dissolved urate of ammonia separates 
from the filtered solution as a granular precipitate. On 
treating it under the microscope with a little mineral acid, it 
gradually disappears, and is replaced by crystals of uric 
acid. 

As the other urates, which, however, seldom occur in 
calculi, exhibit the same reaction, we must carry our re- 
searches further, in order to be convinced of the presence of 
urate of ammonia. We must extract the pulverized calculus 
with cold water, previous to its treatment with boiling water, 
in order to make sure that it is freed from any ammoniacal 
constituents of the urine that might be present. The urate 
taken up by extraction with hot water, may then be shown 
in two ways to be urate of ammonia. If we burn it, it will 
be found to be entirely volatile, while the urates with fixed 
bases leave an incombustible residue ; and if we treat it with a 
weak solution of potash, and apply a gentle warmth, it 
developes ammonia, which may be detected by the smell, by 
the white vapour produced on holding over it a glass rod, 
moistened in hydrochloric acid, or by its communicating a 
blue tint to red litmus paper placed above it. 

The other urates— the soda, magnesia, and lime salts — 
do not often form the sole constituent of urinary calculi, but 
sometimes occur in larger, or smaller quantity in calculi of 
which the principal mass consists of other substances. 

The means of detecting these salts are similar to those 
employed for the urate of ammonia. They must first be 
obtained in a state of purity by extraction with hot water, 
filtration, and evaporation. On the application of a strong 
heat, the uric acid is destroyed, and the composition of the 
residual fixed basis must be determined by the ordinary rules 
of inorganic chemistry. 

Causes and mode of formation of these concretions. The 



CALCULI OF URIC ACID. 



353 



ordinary proximate cause leading to the formation of all cal- 
culi containing uric acid is a peculiar condition of the urine — 
its saturation with urates. 

The practised physician detects this property of the urine 
by observing, that on cooling it becomes turbid, and deposits 
a sediment consisting of urate of ammonia. But, besides 
this, there is a second condition requisite, namely, that a por- 
tion of this excess should be precipitated either as urate of 
ammonia or as free uric acid, in the urinary passages within the 
body. In by far the larger number of cases, the precipitate 
consists of uric acid, arising from the urate being decomposed 
by a free acid in the urine ; the uric acid being much less 
soluble in urine than its salts, the greater portion becomes 
separated. 

Whether the urates can separate from the urine, as a pri- 
mary precipitate within the body, appears to me to be doubt- 
ful, since the ordinary cause giving rise to the formation of a 
sediment of urates — namely, the cooling of the urine- 
does not occur there. Such a precipitate may, however, be 
formed if urine, saturated with urates, remains for a long 
time within the bladder, and loses water in consequence of 
endosmotic action established with the blood. The above con- 
ditions do not, however, lead to the formation of a stone, but 
merely of a precipitate, which frequently consists of such 
minute granules that they can only be detected by the micro- 
scope, and do not form a sediment till the urine has stood for 
some time. From these precipitates there may be formed 
urinary gravel, if its constituents, in consequence of any of 
the above-mentioned causes, adhere within the body, and there 
form larger masses. For the production of a stone, it is 
requisite that there should first be a nucleus formed ; this may 
consist of uric-acid gravel retained in the urinary passages 
in consequence of its size or position, or a clot of mucus, 
blood, or fibrin, or a foreign body. For the formation of a 
uric-acid calculus, it is requisite that the above-mentioned 
uric-acid diathesis should persist for some time, that is to say, 

VOL. I. A A 



354 



PATHOLOGICAL EPIGENESES. 



that there should be a continuous excess of urates in the 
urine. The precipitates separated from the urine then deposit 
themselves by preference, around the nucleus ; these precipi- 
tates may consist either of uric acid liberated by the presence 
of a free acid, or of urates, which separate themselves from 
the saturated urine, in consequence of the presence of a stone. 

Such are the formative relations of calculi containing uric acid, as far 
as morbid anatomy has yet taught us. The investigation of the causes 
inducing this diathesis, fall under the department of general pathology. 
Chemistry has been directly applied by Liebig and others to its eluci- 
dation. It, at least, points out the path which the investigator must 
follow, even if the special results already attained, are not to be regarded 
as decisive. In accordance with these principles, the occurrence of the 
uric-acid diathesis must be explained in the following manner.* 

It can hardly be doubted that the greater part of the protein- com- 
pounds contained in the nutriment and in the constituents of the body, 
are metamorphosed into urea and uric acid, and in this form are dis- 
charged by the urine, even if we are ignorant of the intermediate links 
between the protein on the one hand, and the urea and uric acid on the 
other. This metamorphosis can only be effected by the addition of 
oxygen, as may be shown by calculation ; and undoubtedly more oxygen 
is requisite to convert, theoretically, one atom of protein into urea, car- 
bonic acid, and water, than is necessary to form uric acid, with carbonic 
acid and water : for 

1 equiv. protein. . . =-- H 36 N 6 0 14 

f 3 equiv. urea. . = C 6 H 12 N 6 O g 

is equivalent to < 42 „ carbonic acid. . = C 42 

[24 „ water. . = 0 24 

C43 H 36 N 6 0 114 

Hence in this metamorphosis there are consumed 100 equivalents of 
oxygen. 

But if, in place of urea, uric acid is formed, the case is different : 
1 equiv. protein yields 

3 equiv. uric acid. . . = C M H 6 N 6 0 9 
33 ,, carbonic acid. . = 0 66 

30 „ water. = H 30 

C 4S H 36 N 6 O 105 

* See H. Bence Jones on gravel, calculus, and gout, London, 1842; 
Valentin's Lehrbuch der Physiologie, vol. i. p. 759, &c. 



CALCULI OF URIC ACID. 



355 



Hence for the conversion of protein into uric acid, there are required 
only 91 equivalents of oxygen. This explains how a diminished quan- 
tity of oxygen may be the cause of the formation of an extraordinary 
quantity of uric acid in the body, at the expense of the urea. Extending 
these considerations to the food, we see how certain forms of diet favour 
this uric-acid diathesis. As in the metamorphosis of protein, the greater 
part is discharged as urea and uric acid, so it cannot be doubted that many 
kinds of food devoid of nitrogen, at the termination of their metamor- 
phoses, are for the most part discharged as carbonic acid and water. More- 
over, for this purpose a combination with oxygen is necessary, which is 
supplied to the body by respiration. We may, however, show how 
different sorts of food require different quantities of oxygen, in order to 
effect this metamorphosis. 

Thus 100 parts of starch ( = 44.5 C + 6,2 H + 49.3 O) require : 
118.5 parts of oxygen in order to form (163 C 0 2 (44.5 C + 118.5 O), 
and 55.5 H O (6.2 H + 49.3 O). 

100 parts of sugar (= 42.2 C + 6.4 H + 51.4 O) require : 
112.4 parts of oxygen to yield 154.6 C 0 2 (42.2 C + 112.4 O), and 
57.8 HO (6.4 H + 51.4 O). 

100 parts of fat (= 79 C + ll H + 9 O) require: 
289 parts of oxygen to form 289 C 0 2 (79 C-f-210 O), and 99 H O 
(11 H + 88 O). 

100 parts of alcohol ( = 52.2 C + 13 H + 34.8 O) require : 
208.4 parts of oxygen to form 191.2 C 0 2 (52.2 C+ 139 O), and 117.2 
HO (13 H + 104.2 O). 

If under certain conditions of life the quantity of oxygen taken into 
the body be sufficient to convert into urea, carbonic acid, and water, 
those constituents of the food which consist especially of starch and 
sugar, together with the protein- compounds, we may easily conceive 
that in food rich in fat, associated with a free use of alcohol, the 
oxygen is no longer sufficient for the perfect conversion of the protein- 
compounds into urea, but that, in the place of the latter, uric acid will be 
formed. Experience also teaches us, that food, when of a fatty nature, 
and the copious use of alcohol, together with an imperfect supply of the 
oxygen necessary to respiration, favour the uric-acid diathesis. At all 
events, the above observations point out the way which may lead to a 
true explanation of this formation, although we must not forget that there 
may possibly be many acting intermediate agents with which we are 
unacquainted, and that the above statement can therefore only be re- 
garded as hypothetical. 

2. Calculi of urous acid (uric or xanthic oxide) are of rare 

A A 2 



356 



PATHOLOGICAL EPIGENESES. 



occurrence, but resemble, in every respect, those consisting of 
uric acid. 

A stone consisting of this substance, which was examined 
by Wohler, was externally of a light brown colour, mixed 
here and there with white ; on making a fracture it exhibited 
a faint brownish flesh-colour, and was found to consist of 
concentric layers ; by friction it acquired a wax-like polish, and 
was of about the same hardness as uric-acid calculi. 

The characteristic chemical reaction of this substance consists 
in its solubility in nitric acid without effervescence, and on the 
solution leaving after evaporation a substance of a bright lemon 
colour, which is not soluble in water, but is changed to a deep 
reddish yellow by caustic potash. The characteristic purple 
which uric acid exhibits when acted on by nitric acid and am- 
monia, is in no way to be compared with the above-named 
substance. # 

The structural relations of these calculi are unknown, but 
are most probably the same as those of the uric-acid calculi. 
Thus the same reasons which have been given concerning the 
formation of the uric-acid diathesis, may also explain the origin 
of this substance, since uric oxide exhibits no difference in its 
chemical composition from uric acid, excepting that it con- 
tains an atom less of oxygen than the latter. It is, therefore, 
probably formed, instead of urea and uric acid, from a defi- 
ciency of oxygen in the metamorphosis of the tissues. 

3. Calculi of cystin (cystic oxide) are also rare, although 
less so than those of uric oxide. They are yellowish, of a smooth 
surface, and exhibit a crystalline appearance on fracture. 
The diagnosis of these calculi, and likewise of sediments con- 
sisting of cystin, will be most readily determined by the com- 
bined application of chemistry and the microscope. Cystin is 
almost entirely insoluble in water, but dissolves easily in 
alkalies. If its solution in caustic ammonia be left to evapo- 



* See Wohler und Liebig's Annalen der Pharmacie, vol. 
Part 3. 



CALCULI OF OXALATE OF LIME. 357 

rate, very well marked crystals — regular hexagonal tablets — 
appear ; they are, in fact, tabular prisms. # But if the cystin 
be dissolved in a dilute mineral acid, and the solution suffered 
to evaporate at a moderate heat, groups of divergent radiating, 
acicular crystals appear. Cystin is also characterized by 
containing a considerable quantity (25.5-g-) of sulphur. On this 
circumstance is founded a method, proposed by Liebig, for 
ascertaining the presence of cystin. The calculus is dissolved 
in a strong alkaline solution, to which are added a few drops of 
acetate of lead, but no more than can be retained in solution. 
When this mixture is boiled, a black deposit of sulphuret 
of lead is precipitated, which gives it the appearance of ink. 

Calculi of cystin appear to be most prevalent in children. 
Scarcely anything is known of their formation, relations, or 
the causes of their origin, although we may conjecture that 
the sulphur in the protein-compounds has something to do 
with the formation of cystin. 

4. Calculi of oxalate of lime are tolerably frequent, and are 
either moderately large, with a rough surface, jagged, verru- 
cose, and of a dark brownish colour — in which case they are 
named, from their peculiar appearance, mulberry calculi — or 
they are small, more faintly coloured, and smooth, and are 
then termed hempseed calculi. They may be best known by 
the following reactions — they are insoluble in caustic potash, 
but dissolve without effervescence when boiled in hydrochloric 
acid. If a portion of the stone is heated before the blow-pipe, 
and then moistened with a drop of water, it exhibits an alka- 
line reaction, in consequence of caustic lime having been 
formed. The solution of the heated mass in water is preci- 
pitated by oxalic acid. 

The causes from which these calculi originate are also in a 
great measure unknown, although in some cases their origin 
may be explained by the action of oxalic acid which has been 
introduced into the body by food, &c. Thus, after partaking 



* See Simon, op. cit. Plate in. fig. 32, 



358 



PATHOLOGICAL EPIGENESES. 



of food containing oxalic acid, as sorrel, &c. a sediment of 
oxalate of lime appears in the urine, and a long adherence to 
a similar diet may give occasion to the formation of these 
calculi. But it is not in every case that their origin can be 
explained by the oxalic acid taken in the food ; and we are 
hence led to the conjecture that it may be formed in the or- 
ganism from other substances. Indeed, Liebig and Wohler 
found in their investigations regarding the products of the 
decomposition of uric acid, that on treating it with peroxide 
of lead or with nitric acid, oxalic acid, together with other 
substances, was formed. And this fact renders it highly 
probable that oxalic acid may be formed in the organism from 
other substances ; but what these are, and under what condi- 
tion it is formed, are questions which it is impossible at 
present to answer. At all events, oxalate of lime does not 
exist in the blood, since it could not pass undissolved into 
the urinary canals. Oxalic acid must either pass into the 
urine in a free state from the blood, or in some soluble 
combination, and there unite with the lime, forming an 
insoluble compound. 

5. Calculi of earthy phosphates (phosphate of lime and 
ammoniaco-magnesian phosphate.) Calculi of phosphate of 
lime alone are very rare • those consisting only of ammoniaco- 
magnesian phosphate less so, while the most frequent present 
a combination of both salts. These calculi are of a whitish 
colour, sometimes earthy, chalky, very light and porous; 
sometimes laminated, in which case they are usually firmer. 
Those which especially contain calcareous salts are not easily 
fusible by the blow-pipe ; they become more readily fusible in 
proportion as the magnesian salts predominate, when they are 
termed fusible calculi. They are characterized by dissolving 
in acids without effervescence, and by being precipitated 
unchanged from an acid solution by means of ammonia. 
The following points may serve to decide whether a stone 
contain more lime or magnesia: — 1. The degree of fusibility 
before the blow-pipe. 2. If the acid solution of such a stone 



CALCULI OF EARTHY PHOSPHATES. 



359 



be saturated with ammonia, and then decomposed by oxalic 
acid, the lime alone, as oxalate of lime, will be precipitated. 
If the filtered solution be treated with an excess of ammonia, 
ammoniaco-magnesian phosphate is precipitated in the pre- 
viously described crystalline form, and we may then draw a 
comparison between the quantity of magnesian and calcareous 
salts. 

The formation of these calculi is clearly explained by the 
facts we have already laid down. The urine always contains 
phosphate of lime and phosphate of magnesia. If from any 
cause it becomes ammoniacal, both salts are precipitated. 
But if, on the other hand, it contains an excess of carbonate 
of potash or of soda, then the phosphate of lime is alone pre- 
cipitated. As the latter change of the urine occurs much 
less frequently than the former (only after the conti- 
nued use of alkaline carbonates, and of vegetable salts 
which are converted in the organism into carbonates, while 
carbonate of ammonia very frequently occurs in the urine 
from the decomposition of urea,) and as phosphate of mag- 
nesia is generally found in larger quantities in the urine than 
phosphate of lime, it is easily explained why the magnesian 
salts should occur more frequently in urinary calculi than 
phosphate of lime. As soon, therefore, as conditions tending 
to render the urine continuously alkaline are established, a 
simple precipitate will probably be converted into a stone ; and 
in this manner a calculus of this kind may be gradually formed. 

6. Differing from the calculi already considered, are those 
which appear to consist wholly, or partially, of indifferent 
organic matter (fibrin and other protein-compounds, mucus, 
&c.) They have hitherto been only seldom observed (by 
Marcet, Morin, A. Cooper, Brugnatelli, and Scharling.) Con- 
cretions of this nature are almost entirely consumed before 
the blow-pipe, and yield an odour of burnt horn ; they are 
insoluble in acids, but dissolve in alkalies, and exhibit no trace 
of crystallization. 

They are produced in an entirely different manner from 



360 



PATHOLOGICAL EPIGENESES. 



other urinary calculi, their formation resembling that of con- 
cretions occurring in the parenchyma of organs, which we 
shall consider presently ; they arise either from vesical mucus, 
or more frequently from coagula of blood and fibrin which 
accumulate in the pelvis of the kidney or in the bladder, and 
subsequently experience further changes. 

It is only in rare cases that we find urinary calculi so simple 
as we have described them ; they generally contain several 
constituents, not merely those we have named, but also a 
small quantity of carbonate of lime, carbonate of magnesia, 
and silica. These are often variously associated ; sometimes 
two only occur, sometimes more, sometimes all are found 
combined in a single stone. Thus there are calculi which 
consist of a mixture of uric acid and urates ; others of uric 
acid and urates with earthy phosphates ; and others, again, 
which are formed from a combination of oxalate of lime and 
earthy phosphates. Some calculi have been found to contain 
uric acid, oxalate of lime, phosphate of lime, urate of am- 
monia, carbonate of lime, and ammoniaco-magnesian phosphate, 
being thus composed of six different substances. # These 
different constituents are sometimes intimately united, but 
more frequently disposed in more or less regular layers, so that 
the same calculus may exhibit different chemical properties in 
the different strata, which have evidently arisen at various 
periods. The relations and order of deposition of these laminae 
differ considerably in different cases. f 

The progress of these varying laminae in the same stone 
may, in most cases, be explained with tolerable satisfaction by 
the aid of the observations we have already made on the mode 
of formation of the individual calculi, and throws a new light 
upon the manner in which these concretions are produced. 

* Loir, Journ. de Chimie medic. Sept. 1834. 

t See Berzelius, op. cit. p. 501 ; Sandifort, Museum anatomicum, 
vol. in.; Bence Jones in Medico -chirurg. Transactions, 1843, p. 100, 
&c. 



ALTERNATING CALCULI. 



361 



Thus we have alternating laminae of uric acid and urates, if in 
a prolonged uric-acid diathesis the urine is occasionally very 
acid, by which the urates are decomposed, and uric acid sepa- 
rated ; while at other times, on the contrary, the excess of 
acid abates, and urate of ammonia is deposited from the satu- 
rated fluid upon the surface of the stone. When the uric acid 
alternates with the oxalic diathesis, alternating laminae of 
uric acid or urates and oxalate of lime are formed. The by 
no means uncommon calculi of uric acid or oxalate of lime 
with earthy phosphates, arise when the uric-acid or oxalic 
diathesis periodically abates, and in the interval the urine be- 
comes ammoniacal by the decomposition of urea. This alkaline 
tendency is further increased by a copious discharge of mucus 
from the irritation of the stone, and the occasional retention 
of the urine by the stoppage of the urethra, or the outlet of 
the bladder. 

The alternating laminae of uric acid and phosphate of lime 
in the same stone may sometimes be induced by medicines — 
as the alkalies — which are given to hinder the enlargement of 
the uric-acid calculus, but may, in making the urine alkaline, 
induce an augmentation by the deposition of phosphates. 

The nucleus of urinary calculi is often differently composed 
from the rest of the body. Crosse # found the nuclei of one 
hundred stones thus composed : seventy-two consisted of uric 
acid and urate of ammonia, nine of uric acid and oxalate of 
lime, fourteen of oxalate of lime, one of carbonate of lime, and 
two of earthy phosphates. In other cases the nucleus was 
found to consist of cystin, of organic matter, coagulated blood, 
mucus, or some foreign body. Sometimes the stone exhibits 
a cavity instead of a nucleus in its interior ; in these cases the 
nucleus was probably formed of mucus, which subsequently 
dried up. In some rare cases the nucleus has been known 

* On the Formation, Composition, and Extraction of Urinary Cal- 
culi, London, 1835; G. O. Rees, an Introduction to the Chemical 
Analysis of the Blood and Urine, London, 1845. 



362 



PATHOLOGICAL EPIGENESES. 



to rattle within the stone, which could only be explained by a 
similar drying of mucus. Sometimes the calculus consists of 
gravel or several minute stones, united together by a cement 
which is occasionally of the same nature as the concretions. 

The occurrence of urinary calculi depends, as has been 
before mentioned, upon diet, but also on climate and other 
local relations, such even as the nature of the soil. 

The further prosecution of this inquiry, however important 
it may be to the right knowledge of the origin and mode of 
treatment of urinary calculi, appertains, more properly speak- 
ing, to pathology than to pathological anatomy. * 



We must accurately distinguish from urinary calculi those 
concretions which are not formed in the urinary system, but 
in the organs of generation. 

To these belong concretions of the prostate gland. Pros- 
tatic calculi have, for the most part, very characteristic 
properties, by which they may be easily recognized ; they are 
always small, somewhat about the size of a pin's head, and 
are usually of a brownish, reddish-brown, or yellowish-brown 
colour. They are crystalline or laminated, and frequently 
exhibit a polyhedric or facetted surface, like a granule of 
phosphate of lead fused before the blow-pipe. Their chemical 
constituents are phosphate of lime, with a little animal and 
colouring matter. 

They are doubtlessly formed by a precipitate of phosphate 
of lime, but the causes which tend to their formation are not 
accurately known.f 

* See Windemuth, de lithiasi endemica, Marburgi, 1842; a work 
with copious references ; and H. Textor, Versuch iiber das Vorkom- 
men der Harnsteine in Ostfranken, Wurzburg, 1843. 

f For further information regarding prostatic concretions, see Gluge's 
Untersuchungen, Part 1, p. i)0 ; Cruveilhier, Anatomie pathol. liv. 30, 
pi. i. ; Dupuytren in Meckel's Archiv. vi. 3. 



SALIVARY CONCRETIONS. 



363 



An illustration of the quantitative composition of these concretions is 
given by an analysis by Lassaigne. It yielded in 100 parts : 

Basic phosphate of lime. . . .84.5 

Carbonate of lime 0.5 

Animal matter (mucus, &c.) . . 15.0 

Concretions of similar chemical composition are sometimes 
found in the vesiculae seminales and the vasa deferentia. They 
are formed, doubtlessly, like prostatic calculi, from the 
secretion of these glands, when from any cause it contains 
more calcareous salts than in the normal condition. A pre- 
cipitate then occurs, which, under favourable conditions, passes 
into a concretion. 

Peschier found in 100 parts of such a concretion : 

Phosphate of lime. . . 90 
Carbonate of lime. . . 2 
Animal matter. . .10 

Similar concretions are found in the female generative 
organs, consisting chiefly of earthy phosphates, which are 
formed in a similar manner as urinary calculi composed of 
the same substance. 

Illustrations : A large calculus in the uterus, the nucleus, of which 
was a part of the tibia of a fowl, (consequently an incrustation), consisted 
of phosphate of lime. Another large stone in the uterus consisted of 
ammoniaco-magnesian phosphate, surrounded by phosphate of lime 
(Brugnatelli) . A concretion from the vagina of an old woman was of a 
yellowish white colour, and consisted of phosphate of lime with animal 
matter (mucus ?) which remains in flocculi on dissolving the concretion in 
hydrochloric acid. (Thomson).* 

II. SALIVARY CONCRETIONS. 

The saliva contains amongst its normal constituents a very 
small number of those substances which, under favourable 
circumstances, might give occasion to the formation of an 
insoluble precipitate. These are the insoluble earthy salts 
(phosphates of lime and magnesia) whose solution is probably 



* Leop. Gmelin, Chemie, n. 2, 1372. 



364 



PATHOLOGICAL EPIGENESES. 



occasioned by an unknown combination with organic sub- 
stances, and soluble salts of lime, which, under certain condi- 
tions, can be converted by chemical decomposition into 
insoluble carbonate of lime. If the quantity of these 
constituents be abnormally increased, and if at the same time 
conditions occur by which their solution in the saliva is 
hindered, a precipitate occurs. This precipitate is either car- 
ried off with the discharged saliva as quickly as it is formed, 
or it remains, accumulates, and unites so as to form larger 
masses — concretions. Salivary concretions are, however, of 
two kinds, forming salivary calculi, and the tartar of the 
teeth. 

Salivary calculi are formed when the precipitate occurs 
within the salivary glands, and there accumulates (in accord- 
ance with the general laws regulating the formation of con- 
cretions), frequently attaining such a size as to close up the 
excretory ducts, and prevent their being voided. Salivary calculi 
are thus continually increasing, by always receiving new preci- 
pitates. They occur either in the parenchyma of the salivary 
glands or in their excretory ducts. They are roundish or oblong 
concretions, varying from the size of an almond or olive, to that 
of a pigeon's egg, and are of a whitish colour ; they are some- 
times definitely laminated, consisting of concentric layers, some- 
times of indistinct laminse ; they have a chalky, dead-white 
appearance, and are usually easily pulverized, but occasionally 
as hard as stone. They sometimes enclose a hard, thick 
nucleus of a greenish colour. Their principal constituents 
are always calcareous salts, viz., carbonate of lime united with 
animal matter (mucus, or modified protein.) 

If the precipitate does not occur in the salivary glands, but 
is first observed in the buccal cavity, it deposits itself over the 
whole surface of the mouth. Thus, on examining the fur 
on the tongue, we often find the epithelial cells encrusted with 
a granular deposition of calcareous salts. But as the epithe- 
lial cells of the cavity of the mouth are being constantly 
abraded, the precipitates cannot of course accumulate to form 



SALIVARY CONCRETIONS. 365 

concretions. It is only to the teeth, (and then from want of clean- 
liness,) that such an adhesion is possible, and thus we are able 
to explain the formation of the tartar which is deposited around 
the base of the gums, the body of the tooth, and between the 
teeth, exhibiting, when broken off, hardish particles of a 
grayish-white colour. The formation of this tartar is pro- 
bably more dependant on an increased quantity of lime in the 
secretion of the minute glands of the buccal cavity, than on 
a similar alteration in the saliva. 

An analysis made by S. Wright* will show how much the quantity of 
the calcareous salts of the saliva may be increased by morbid processes. 
The quantity of phosphate of lime which is only 0.6 in 1000 parts of 
normal saliva was once found to be increased to 14. And in some 
previous observations of the same author, the saliva was so calcareous 
that it stiffened to a white chalky mass. 

The following tables will give an idea of the quantitative composition 
of salivary calculi. They contained in 100 parts : 





l 


2 


3 


4 


5 


6 


7 


Carbonate of lime 


81.3 


79.4 


80.7 


13.9 


20 


15 


2 


Phosphate of lime 


4.1 


5.0 


4.2 


38.2 


75 


55 


75 


Phosphate of magnesia 








5.1 




1 




Soluble salts 


6.2 


4.8 


5.1] 










Animal matter 


7.1 


8.5 


8.3 J 


> 38.1 




25 


23 


Water and loss 


1.3 


2.3 


1.7 


6.3 


u 


2 






100.0 


100.0 


100.0 


101.6 


100 


98 


100 



1 — 3. Salivary calculi analyzed by Wright, op. cit. p. 57. 

4. v. Bibra. Medicin Correspondenzblatt fur baierische Aerzte, 1843. 

No. 47. The stone had a specific gravity of 0.933, contained only 
in the nucleus, mucus and albumen. The above analysis ex- 
plains the composition of the lamina surrounding the nucleus. 
It contained together with 35£ of organic substances 3.1£ fat 
with traces of soda. 

5. Lecanu. This calculus consisted of a hard thick nucleus of a gray- 

ish colour with a white and easily pulverizable capsule. L. Gme- 
lin's Chemie, n. 2, 1399. 

6. Besson in Gmelin, op. cit. The stone was taken from the Whar- 

tonian duct of a woman, aged sixty years ; it was roundish, 

* Der Speichel, in Dr. Eckstein's Handbibliothek des Auslandes, 
Wien, 1844, p. 173. 



366 



PATHOLOGICAL EPIGENESES. 



white, pulverizable, and consisted of concentric layers ; its specific 
gravity was 2.30. It contained, besides the above named consti- 
tuents, 2% peroxide of iron.(?) 
7. GoldingBird. Die Harnsedimente, Handbibliothek des Auslandes, 

edited by Dr. Eckstein, p. 93. 
For further analyses see Berzelius' Chemie, vol. ix. 4th edit. p. 229 ; 
John in Meckel's Archiv. vi. 4 ; Rath im Baumgarten's Zeits. von 
Chirurgen fur Chirurgen, vol. i. Part 2, p. 29, &c. 

Tartar from the teeth was found to be composed of : 





1 


2 


Earthy phosphate (lime and magnesia) 


. 79.0 


66 


Carbonate of lime. .... 




9 


Mucus (with epithelium ?) 


. 12.5 


13 


Ptyalin. . .... 


. 1.0 




Animal matter soluble in hydrochloric acid. 


. 7.5 


5 


Water. . .... 




7 




100.0 


100 



1. Berzelius. 2. Vauquelin and Laugier.* 

Denisf has examined the brown fur of the tongue in cases of deranged 
digestion, after it had been scraped off with an ivory knife and dried. 
It then formed a firm, translucent, yellowish gray mass, which con- 
tained no crystals. Its chemical composition was as follows : 



Phosphate of lime. . . 34.7 

Carbonate of lime. . . 8.7 

Altered mucus (epithelium, &c.) . 50.0 

Loss. .... 6.6 



100.0 

The sordes attached to the teeth of the same person were simi- 
larly composed. If, therefore, we except the fact that the depositions 
on the tongue must contain many more epithelial cells than the tartar 
of the teeth, there is a striking resemblance in the chemical composition 
of both, and it appears clear that they must originate from the same 
causes. According to Mandl, the formation of tartar is in no way con- 
nected with the increased quantity of lime in the saliva, but produced by 
the skeletons of dead infusoria, agreeing in form with those of the 
vibriones which deposit themselves in viscid matter, and between the 
teeth, and thus form concretions. This view appears to me to be wholly 

* Berzelius, Thierchemie, 4th edit. p. 228. 
t L. Gmelin, n. 2, 1397. 



LACHRYMAL CONCRETIONS. 



367 



untenable. I certainly have occasionally, but not always found vibriones 
in large numbers in the fur of the tongue, and in the viscid matter 
around decayed teeth, &c. ; they had, however, no calcareous skeletons, 
while on the other hand, granular precipitates of calcareous salts were 
to be met with together with these vibriones. If, therefore, the latter 
play any part in the formation of tartar, it must be a very subordinate 
one. 

III. LACHRYMAL CALCULI. 

These occur under similar circumstances to salivary concre- 
tions. Although, in the normal state, tears form a very 
watery fluid, they contain a small quantity of calcareous salts, 
which, when considerably increased by pathological conditions, 
can give rise to concretions. These are either formed in the 
lachrymal glands, in the eye, the lachrymal ducts, or the 
lachrymal sac. In the latter concretions, the fatty matter 
secreted by the meibomian glands occurs as one of the con- 
stituent parts. 

Fourcroy and Vauquelin found in calculi of the lachrymal gland, a 
preponderance of phosphate of lime. The chemical composition of these 
concretions is often very complicated, as the following analyses show. 
These concretions contained in 100 parts : 





1 


2 


Phosphate of lime. 


47.3 


9 


Carbonate of lime. 


8.4 


48 


Carbonate of magnesia. 


1.1 




Peroxide of iron. .... 


0.9 




Chloride of sodium with soluble earthy matter. 


5.9 


Traces 


Mucus. ..... 


20.3 


18 


Albuminous matter. 




25 


Fat. ..... 


11,9 


Traces 


Water. ..... 


3.0 






98.8 


100 



1 . A concretion formed in the eye of a blind man, and examined and 
analyzed by Wurzer, (Berzelius, Thierchemie, p. 722). Yet it 
seems questionable to me whether this concretion can be reckoned 
as appertaining to lachrymal calculi. The fat was probably a 
product of the secretion of meibomian glands. 



368 



PATHOLOGICAL EPIGENESES. 



2. A lachrymal concretion found by Desmarres in the lachrymal duct 
and sac, weighed about six grains, and had a specific gravity 
of 1 .4 : analysed by Bouchardat, (Annales d'oculistique, Aout, 
1842). 

Other cases may be found in Walther's Journal der Chirurgie, 1820, 
p. 164; Sandifort's Observat. anat. patholog. vol. m. p. 71, where 
many older cases are referred to. 

4. Concretions in the nostrils, the throat, the tonsils, and 
the bronchi, originate in the same manner as salivary calculi, 
and have a similar chemical composition. 

Such concretions sometimes occur as incrustations around foreign 
bodies. Ruysch relates* that an amber bead which had accidentally 
lodged in the nose of a child of five years of age, and was not ex- 
pelled until the girl attained her fourteenth year, was surrounded by 
a stony crust. The same authority gives another case, where the 
same thing occurred with a cherry stone. Grandoni describedf a stony 
concretion, which had formed in the left nostril of a woman, and was 
extracted with the forceps. It weighed seventy-six grains, and con- 
tained phosphate and carbonate of lime, carbonate of magnesia, and 
organic matter with traces of iron. Two other forms of concretions 
had the following composition : 





1 


2 


Phosphate of lime. 


46.7 


79.56 


Carbonate of lime. 


21.7 


6.41 


Carbonate of magnesia. 


8.3 




Chloride of sodium and other soluble salts 


>. Traces 


0.58 


Animal matter. 


23.3 


4.52 


Water. .... 




8.93 




100.0 


100.00 



1. A concretion from the nose, which had occasioned a periodical 

hemicrania ; it was of a yellow- grayish colour, and earthy : ana- 
lysed by Geiger. The animal matters were noted as mucus, 
fibrin, osmazome and fat, (L. Gmelin, n. 2, 1397). 

2. A concretion from the nose of a woman aged seventy years : ana- 

lyzed by Brandes, (Berzelius, vol. ix. p. 722). 
A concretion from the tonsils analysed by Laugier, was greyish- white, 

* Observat. anatomico-chirurg. centuria. Observ. 45. 
f Omodei annali universali di medicina. Ottobre, 1839. 



GALL-STONES. 



369 



rather hard, verrucose, and consisted of a rough crust, and a white 
nucleus. It contained : 

Phosphate of lime. . . 50.0 

Carbonate of lime. . . 12.5 

Mucus 12.5 

Water 25.0 

100.0 

V. PANCREATIC CALCULI. 

These are of rare occurrence, but appear to be occasionally 
formed from the pancreatic fluid, in the same manner as sali- 
vary and lachrymal calculi are formed from their corresponding 
secretions, and they resemble these latter in their chemical 
composition. 

Golding Bird has examined a pancreatic calculus which contained in 
100 parts : 

Phosphate of lime. . . 80 
Carbonate of lime. . . 3 
Animal matter. . . 7 

90 

(Die Harnsedimente, Handbibliothek des Auslandes, edited by Dr. 
Eckstein, p. 93). 

Plates of pancreatic calculi are given in Baillie's engravings, fasc. 5, 
Plate vn. p. 117. 

VI. GALL-STONES. 

Under this term are included all concretions which are 
precipitated from the bile. They appear in all parts of the 
biliary apparatus, but most frequently in the gall-bladder, 
rarely in the biliary ducts of the liver, in the ductus hepaticus, 
cysticus or choledochus, and in the intestinal canal. 

Gall-stones exhibit great differences in their chemical com- 
position, and vary in a corresponding manner in their physical 
properties. Their chemical constituents are as follows : 

1. Cholesterin, which may easily be recognized by the 

VOL. I. B B 



370 



PATHOLOGICAL EPIGENESES. 



rhombic tablets, in which it separates from a solution of 
the gall-stone in hot alcohol. 

2. Bile pigment (cholepyrrhin of Berzelius, biliphsein of 
Simon,) has a fiery, brownish-red colour, and is easily known 
by its reaction with nitric acid, which changes its colour first 
to green, then to blue, violet, and red ; the mixture lastly 
becoming colourless. It dissolves in boiling potash, producing 
a greenish-brown solution. Several modifications of this 
pigment occur which do not exhibit the characteristic reaction 
with nitric acid ; as for instance, 

3. A dark brown, almost black pigment. 

4. Other constituents of bile, as choleic acid, choleate of 
soda, and their modifications, bilifellinic acid, dyslysin, &c. 

5. Mucus and epithelium of the gall-bladder and the 
biliary ducts. 

6. Earthy salts, namely, carbonate of lime. 

7. Margarin and the margarates. 

These constituents enter in different relations into the com- 
position of gall-stones. They are seldom all found united in 
one stone, and those which are composite are generally blended 
equally, or one constituent predominates over the others. 
Cholesterin is usually the preponderating substance ; chole- 
pyrrhin rarely; in some few gall-stones the black pigment 
occurs in the largest quantity; while carbonate of lime is 
rarely thus met with. 

It is only in very few cases that gall-stones consist princi- 
pally of inspissated bile. 

Gall-stones likewise vary in their physical characters. As 
in urinary calculi, so also here, they may present every transi- 
tion, from a minute precipitate visible only by the microscope, 
to concretions of considerable magnitude. Hence we may 
distinguish between biliary deposits, biliary gravel, and gall- 
stones, which may be either consistent, or soft and doughy. 
The forms of these concretions are likewise variable; sometimes 
they occur as soft, amorphous masses ; sometimes they have a 



GALL-STONES. 



371 



distinct and well-marked shape. When occurring singly they 
are round ; when several are present , they assume a polyhedric 
form. 

There are two kinds of gall-stones which possess very 
characteristic forms— those consisting of crystallized carbonate 
of lime, which are pointed and jagged ; and those formed of 
dark pigment, which usually present a nodulated appearance, 
like mulberry-calculi. The colour of gall-stones depends on 
their chemical constituents, and is hence by no means 
constant. 

The following may be regarded as the principal forms of 
biliary concretions, arranged according to their physical cha- 
racter : 

1 . Fine precipitates of bile-pigment and crystallized choles- 
terin imbedded in mucus, mixed with epithelium whose cells 
are sometimes incrusted. 

2. Biliary gravel — minute concretions of the size of a 
hempseed, or grain of sand ; occasionally many such concre- 
tions are united by mucus so as to form a large mulberry- 
shaped calculus. 

3. Soft biliary concretions, which in a recent state readily 
admit of being moulded between the fingers, consisting of 
crystalline depositions of cholesterin, between which there is 
bile-pigment. # 

4. Crystalline calculi consisting for the most part of cho- 
lesterin, nearly colourless, transparent, with a crystalline 
fibrous fracture, granular on the surface, and usually covered 
with minute crystals of cholesterin. 

5. Dark calculi of a reddish-brown colour, and earthy frac- 
ture which does not become bright by friction. These con- 
sist for the most part of bile-pigment. 

There is a variety of this species, which is of a dark-brown, 
almost black colour, and exhibits a red, mulberry-like appear- 



* See Plate x. fig. 5. 

B B 2 



372 



PATHOLOGICAL EPIGENESES. 



ance. These calculi seem to consist of a peculiar modification 
of bile-pigment. # 

6. Calculi consisting for the most part of carbonate of 
lime : they are crystalline, with rough surfaces terminating in 
sharp angles, of a clear or sometimes rather brown colour.f 

7. Gall-stones of a whitish colour, saponaceous feeling, and 
concentric laminated arrangement, which on scraping assume 
a polished appearance, and consist for the most part of cho- 
lesterin. 

8. Gall-stones consisting of alternate white layers of cho- 
lesterin, and dark yellow layers of bile-pigment. 

The two last kinds are by far the most common. 

Gall-stones frequently exhibit a nucleus differing from the 
remainder of the mass, and consisting for the most part of 
mucus and epithelium coloured by bile-pigment : this, while 
the stone is fresh, is soft ; but, on drying, shrivels up, and 
gives rise to a central cavity. Sometimes the nucleus consists 
of a foreign body — as a worm, or a portion of a needle. J 

The nucleus does not invariably lie in the middle of the 
stone, showing that the growth of the concretion has not 
been uniform ; this is especially observed in calculi sacculated 
in a diverticulum of the gall-bladder. A gall-stone has sometimes 
more than one nucleus, namely, when several originally distinct 
concetions unite with, and become fused into one another. 

The following analyses may serve to give an idea of the varying che- 
mical composition of gall-stones. 

1 2 3 4 5 6 

Cholesterin 96 65 67 50 4 — 



Bile-pigment 
Mucus 

Biliary matter 




Calcareous salts — 2 — 8 3 100? 

~~99 95 84~~ 93 96 

* See Simon's Beitrage zur physiolog. u. pathol. Chemie, Part 1, 
p. 117, with a plate ; Scherer's Untersuchungen, p. 105. 
t Bouisson, de la Bile, 1843, p. 220, Plate ii. fig. 2. 
+ Bouisson, op. cit. p. 245. 



GALL-STONES. 



373 



These analyses made by various chemists are nearly all to be found in 
L. Gmelin's Chemistry, n. 2, p. 1431. I have somewhat modified them 
in order that they might admit of better comparison with each other, 
the biliary matter (choleic acid and its modifications) being determined 
according to the different views maintained by the different chemists. 
Whether the lithofellinic acid detected by Gobel, Wohler, &c, in certain 
intestinal concretions of unknown origin, ever occurs in human gall- 
stones, as some have conjectured, cannot as yet be determined with 
certainty ; it is, however, improbable. Scherer has submitted to ulti- 
mate analysis, the black pigment which occurs in many gall-stones ; 
but in the absence of an analysis of healthy bile-pigment, we have no 
means of ascertaining its deviation from the normal standard. 

The formation of gall-stones follows the same laws as those 
of concretions generally. 

In order that a gall-stone may be produced, it is first neces- 
sary that a precipitate should be formed, and that this should 
not be discharged with the bile, but remain and accumulate 
into a larger mass ; in this manner a nucleus is formed, which, 
under favourable conditions, becomes augmented by further 
depositions. In order that these depositions may take place, 
it is necessary that : 

1. The bile should be in a state of concentration, which 
occurs when it has been retained for a long time in the biliary 
ducts or in the gall-bladder. By prolonged contact with a 
denser fluid — the blood — water is removed from it by the 
laws of endosmosis, and those substances become deposited 
from it which are the most difficult of solution — as the cho- 
lesterin, the bile-pigment, the salts of the fatty acids, and also 
the choleate of soda : the last-named substance is, however, 
very rarely separated, for it is only very seldom that we find 
it in any quantity in biliary calculi. Probably it undergoes 
decomposition even in the biliary passages, since by an acid 
it is converted into fellinic and cholinic acids, and dyslysin — 
substances which probably exist in considerable quantity in 
many gall-stones. However, further experiments are required 
on this subject. 

2. In most cases in which gall-stones are formed, the bile 
is probably more abundant in certain constituents — as for 



374 



PATHOLOGICAL EPIGENESES. 



instance, cholesterin — than in the normal state. It is true, 
that such a peculiarity has never yet been detected by chemical 
analysis, but an augmentation of the cholesterin in the bile, 
is in the highest degree probable, since it is known that in 
advanced age, it increases to a considerable degree in the 
blood. Moreover, an augmentation of bile-pigment appears 
to occur, and to give rise to its deposition. In those rare 
cases in which gall-stones consist entirely, or for the most part 
of carbonate and phosphate of lime, the amount of calcareous 
salts in the bile is probably increased. Moreover, an increased 
secretion of mucus in the biliary apparatus, appears to take 
part in the formation of gall-stones, since it acts as a con- 
necting medium between other precipitated matters, and con- 
sequently prevents their being discharged : moreover mucus 
forms the most common nucleus of gall-stones. 

There are also certain mechanical relations which influence 
the formation of these concretions ; as, for instance, diverticula 
of the gall-bladder or ducts, which receive and retain pre- 
cipitates or foreign bodies forming nuclei around which 
precipitates can be deposited. The concentration of the bile 
caused by its retention appears, however, in most cases to 
be the most efficient agent, even when the other causes are 
also in operation. It is probably also the reason why gall- 
stones are mostly composed of biliary mucus. If a gall-stone 
is once formed, its further enlargement follows very easily, 
since the biliary constituents which are most difficult of solu- 
tion — especially the cholesterin if it be present in tolerable 
quantity— -become deposited on it. Although the preceding 
observations tend in some measure to elucidate the mode of 
formation of gall-stones in general, yet it is hardly possible in 
a given case to explain all the causes influencing the develop- 
ment from the first commencement, till it becomes a per- 
fect calculus. 

The literature of this subject is very abundant. We must especially 
notice the treatise of Bouisson de la bile, pp. 176 — 252, in which are 
contained an immense number of references to the older writers. See 



INTESTINAL CONCRETIONS. 



375 



also J. F. Meckel, Path. Anat. n. 2, p. 455, and Sommering, de 
concrementis biliariis, Francft. 1795. 

We must likewise refer the reader to the chapter on the morbid ana- 
tomy of the liver and biliary apparatus, in the second volume. 

VII. INTESTINAL CONCRETIONS. 

Concretions are not often formed in the human intestinal 
canal, being much rarer than those hitherto considered. We 
meet with them after death in any part of the digestive tube, 
between the stomach and the rectum, or they are removed by 
vomiting, or with the faeces. 

There are two distinct kinds to be considered : 

1. Concretions formed in the intestinal canal itself, from 
its own contents — true intestinal concretions. 

2. Concretions formed in other parts, and which find their 
way into the intestinal canal. 

In the latter class belong all gall-stones, which getting into 
the duodenum are discharged by vomiting or by the rectum, 
or are occasionally found in the intestinal canal after death. 
They may be easily recognized by the characteristic properties 
of gall-stones. That actual gall-stones consisting of biliary 
constituents are primarily formed in the intestinal canal, is 
not improbable, although the individual constituents of the 
bile (modified bilin, dyslysin, &c.) are not rare in true 
intestinal calculi. Moreover, it occasionally seems to happen 
that true gall-stones, when retained for some time in the 
intestinal canal, serve as nuclei for other depositions, and 
then become converted into true intestinal concretions. Pan- 
creatic calculi may also, in some few cases, escape through the 
orifice of the duct, and may be readily mistaken for true 
intestinal concretions, the chemical composition of both being- 
very similar. Moreover, we must not mistake for true intes- 
tinal concretions the hard matter which has been observed 
by Gurlt, as forming in the mucous glands of the duode- 
num. 

True intestinal calculi exhibit great differences in their 



376 



PATHOLOGICAL EPIGENESES. 



characters, their chemical composition, and in their mode of 
formation. They arrange themselves in certain groups between 
which there is no very distinct line of demarcation. 

1 . Many intestinal calculi are formed in precisely the same 
manner as concretions in the parenchyma of organs, of which 
we shall speak presently. Their formation is due to an exu- 
dation of fibrin, or a coagulum of blood retained in the intes- 
tinal canal, and undergoing further changes, the constituents 
soluble in the intestinal fluid being gradually removed and 
merely the insoluble portion — the calcareous salts — remaining. 
Such calculi consist for the most part of protein-compounds — 
coagulated fibrin — mixed with salts of lime and fragments of 
food; they are formed after inflammatory exudation of the 
intestinal mucous membrane, and after hemorrhage into the 
canal. 

To this class belong the concretions which were analysed by Dublanc. 
They were discharged by a child after inflammation of the bowels, and 
formed irregularly shaped, smooth, yellow, hard, transparent pieces 
devoid of taste or smell. They consisted of fibrin with a trace of fat and 
phosphate of lime. Two concretions of a similar nature analysed by 
Davy, yielded in 100 parts : 

1 2 

Fibrin. . . . 78 74 

Salts. . . . 21 7 

Other constituents (pigment, 

resin, fecal matter, &c.) . 5 19 

104 100 

Sometimes these calculi contain a foreign body as a nucleus, as for 
instance, a plum or cherry stone, which in consequence of the inflam- 
matory irritation it excites in the intestinal canal, becomes surrounded 
with fibrinous deposits. 

These intestinal concretions may be known by their insolubility in 
water, spirit, and dilute acids, which last only dissolve the salts of 
lime ; they are partially soluble in a solution of potash. When boiled 
in concentrated hydrochloric acid, they for the most part or entirely 
dissolve, forming a lilac -coloured solution. 

2, A second kind of intestinal concretion consists princi- 
pally of earthy salts (phosphate and carbonate of lime, ammo- 



INTESTINAL CONCRETIONS. 



377 



niaco-magnesian phosphate, and phosphate of magnesia). 
These either form the entire concretion, or are mixed with 
fragments of food, namely vegetable fibres. They frequently 
contain a foreign body as a nucleus. 

These concretions correspond in all respects with the sali- 
vary and lachrymal calculi already described, and are formed 
in a similar manner, namely by the earthy salts dissolved in 
the contents of the intestine becoming from any reason inso- 
luble and being precipitated. Such precipitates are usually 
thrown off from the system, and we frequently meet with 
them in the intestinal excretions. The liquid evacuations of 
persons suffering from diarrhoea, almost invariably contain 
precipitates consisting of ammoniaco-magnesian phosphate, 
and phosphate of lime. 

If these precipitates are retained, and become connected 
together by intestinal mucus, or deposit themselves around a 
foreign body, they give rise to the formation of a concretion. 
Calculi of this sort are most frequently found in diverticula, 
as for instance, in the appendix vermiformis of the caecum. 

The salts forming these calculi seem to rise from two 
sources — partly from the food which contains salts of lime 
and magnesia, and partly from the intestinal fluid itself, 
which, like the tears, saliva, and other animal fluids, under 
certain conditions of which we are ignorant, contains an excess 
of earthy salts. The earthy salts contained in the food are 
dissolved by the acid gastric juice, and if they are not pre- 
viously resorbed, are again precipitated, when the chyle is 
neutralized in a lower portion of the canal by the alkaline 
intestinal fluid. 

About three years ago I found a concretion of this nature in the 
appendix vermiformis of a phthisical patient. It had the thickness of a 
goose- quill, was about an inch in length, and perfectly filled the cul de 
sac of this intestinal diverticulum. It was of a whitish yellow colour ; 
internally it presented a crumbling appearance, while the external por- 
tion was composed of thin, concentric layers. It was easily reduced to 
the form of a white powder, which under the microscope presented an 
indefinitely granular appearance, and dissolved in hydrochloric acid with 



378 



PATHOLOGICAL EPIGENESES. 



considerable evolution of gas. It consisted of carbonate and phosphate 
of lime with a little magnesia. Two concretions of this nature — the 
former analysed by Thomson, and the latter by Davy — contained in 
100 parts : 



1 



56 



Phosphate of lime. . . .46 

Ammoniaco-magnesian phosphate. . 5 

Animal matter (fibrin?). . . 25 42 

Vegetable fibre, resin, &c. . .24 — 



100 98 



Sometimes, as has been already mentioned, calculi of this nature form 
around a foreign body as a nucleus. Children has analysed concretions 
from the large intestine of a man who had swallowed plum-stones. 
They were formed of the stones surrounded by a clear brown, smooth, 
firm mass, consisting of alternate concentric layers of earthy phosphates 
and fibrous matter (the vegetable fibres derived from the food) . The 
outer portion consisted of : 

Animal matter soluble in water, with 1 ^ 

traces of soluble calcareous salts. . J 
Phosphate of lime. . .46 

Ammoniaco-magnesian phosphate. . 5 
Woody fibre. . . .20 

Resin (modified bile ?) . .4 



100 



If the amount of fibrin be increased, these concretions merge into the 
first class ; if the amount of vegetable matter (remnants of food) be 
large, they become almost identical with the third class. They are soluble 
for the most part in acids, which take up their earthy salts. The 
residue is best examined by the microscope which sometimes enables us 
to determine the nature and origin of the concretion. 

3. Many intestinal concretions consist for the most part of 
undigested fragments of food, vegetable cells, &c. They fre- 
quently exhibit a woody appearance, and generally have a 
foreign body as their nucleus. 

The following seems to be the mode of their formation : 
Many portions of our food are absolutely indigestible, as, for 
instance, hair, epidermis, all the woody parts of the vegetables 
in general use, the shells and husks of fruit, &c. These can- 
not be digested, but pass through the system unchanged. It 



INTESTINAL CONCRETIONS. 



379 



can scarcely be doubted that from these cells, united by a 
viscid connecting medium, woody concretions may take their 
origin. But we are ignorant of the conditions necessary for 
the production of this rare form of concretion. Probably 
in this, as in most other concretions of this nature, the presence 
of a diverticulum or a coarctation of the intestine is necessary 
to retain these masses, and thus to allow of the gradual 
formation of a concretion. 

Laugier has analysed a concretion of this nature taken from the 
rectum of a man. It contained as a nucleus, a piece of bone, and was 
surrounded by interwoven vegetable fibres, from which water extracted 
14£ of animal matter, with a stercoraceous odour, together with some 
muriate of ammonia, and chloride of calcium. In a man aged forty- 
one years, who always lived regularly, but subsisted chiefly on vege- 
tables, oat and barley-meal, and pulse, there were formed a large 
number of intestinal concretions, which after causing much pain were 
discharged by the anus. They had a smooth surface, were brown, and 
was formed of concentric laminae ; in the centre there was a nucleus 
resembling dried blood, which was surrounded by a thin layer of carbo- 
nate of lime. The analysis of these concretions yielded albumen, faecal 
matter, fat. soluble vegetable matters and salts, silica, phosphate of 
lime (20£) and fibrous matter (36£) consisting of undigested remains 
of oat grains.* An intestinal concretion which had formed around 
a cherry-stone, consisted chiefly of the colouring principle of rhubarb, 
together with phosphate of lime and ammoniaco-magnesian phos- 
phate, f 

Intestinal concretions of this class naturally exhibit very different 
physical and chemical characters, according to the nature of their pre- 
dominating ingredient. The best method of ascertaining their nature is 
by a microscopic examination of the residue left after successive extrac- 
tions with water, acids and alkalies. 

4. Other concretions consist for the most part of fatty matters, 
with which a little fibrin and salts of lime are usuallv combined. 
They must not be confounded with gall-stones consisting of 
cholesterin. We know less of the mode of formation of this 

* London and Edinburgh Monthly Journal of Medical Science, vol. i. 
p. 630. 

f Valentin's Repertor. 1837, p. 118. 



380 



PATHOLOGICAL EPIGENESES. 



class of concretions than of any of the preceding. It must 
remain still undecided whether they derive their fat directly 
from the food, or whether they obtain it from the secretion of 
the intestinal canal and the glands connected with it. In all 
probability they may obtain it from both sources, but, I 
conceive, more frequently from the former than the latter. 

In order to give an idea of the chemical composition of these concre- 
tions, I will give two analyses, one made by Lassaigne and the other by 
Robiquet. 

Lassaigne. Robiquet. 

Fatty matters. 74 60 

Animal matter. . .21 8 

Phosphate of lime. 4 30 

Chloride of sodium. 1 — 

100 98 

The concrements analysed by Lassaigne were discharged from the 
bowels of a phthisical girl. They were passed in great numbers, varied 
from the size of a pea to that of a musket-ball, were laterally com- 
pressed and smooth ; externally they were of a yellow colour, internally 
they were white and granular ; and they could be easily pulverized. 
The fat appeared for the most part to consist of the fatty acids (oleic 
and stearic (?) acids) ; the animal matter resembled fibrin, and was 
undoubtedly a protein-compound. In Robiquet' s case, the fat resem- 
bled spermaceti ; no particulars are given of the animal matter. 

Caventou has likewise analysed fatty intestinal concretions, which 
were surrounded with a coriaceous membrane. 

Such concretions may be recognized by their being for the most part 
soluble in boiling alcohol, and by the fat not separating, as the solu- 
tion cools and evaporates, in the tablets which indicate cholesterin. 
They fuse when heated, and burn with a clear, but carbonaceous 
flame. 

Some concrements which have been regarded as intestinal 
calculi probably owe their origin to some other source. This 
is not merely the case with biliary and pancreatic calculi, but 
with certain others. Thus Brugnatelli analysed concretions 
which were stated to be passed from the rectum of a woman, 
and which were composed of urate of ammonia with a little 
phosphate of lime, and a tolerably volatilizable animal matter 



CONCRETIONS IN THE CUTANEOUS GLANDS. 



381 



of a not unpleasant odour. That intestinal concretions should 
have urate of ammonia for their principal constituent, is so 
improbable, that we must be allowed to suspect that there 
must be some error. I believe that this concretion was either 
not discharged from the rectum, but from the urinary passages 
or the vagina ; or else that in this person there was a com- 
munication between some of the urinary organs and the 
rectum, through which the urine passed, in which case there 
would be no great difficulty in accounting for the presence of 
a concretion of urate of ammonia in the latter organ. 

The literature referring to intestinal concretions is very scattered. 
Most of the illustrations which I have given, may be found in Berzelius' 
Thierchemie, p. 355, and L. Gmelin, n. 2, p. 1446, &c. In the article 
" Enterolithen," by Jaeger,* the reader will find a full and very excel- 
lent account of intestinal concretions in man and animals, together with 
a copious bibliography : a Memoir by Meckel on the concretions in the 
human intestinal canal, and published in the first volume of his Archiv. 
may also be consulted with advantage. 

VIII. CONCRETIONS IN THE CUTANEOUS GLANDS. 

Nearly all the glands of the humau body seem capable, 
through a change of their secretions, of giving rise to the 
formation of concretions, and the minute cutaneous glands, 
although very rarely affected in this manner, form no excep- 
tion to this rule. The anatomical relations of the concretions 
occurring in these glands are still imperfectly known; how- 
ever, it is probable that they occur not merely in the sebaceous 
glands — both those that are free, and those accompanied by 
hair, forming hair-glands — but also in the sudaminous glands 
with spiral ducts. 

Two kinds of these concretions may be distinguished, 
which are, however, associated together, and may pass one into 
the other. 

If the normal or slightly changed secretion is retained 

* Encyclop. Worterbuch der medicinischen Wissenschaften, Berlin, 
1834, vol. ii p. 172—204. 



382 



PATHOLOGICAL EPIGENESES. 



in the gland by the stoppage of the duct, or for any 
other reason, it thickens and forms a concretion. In this 
case the concretion consists principally of those sub- 
stances which constitute the normal secretion, namely fats 
and fatty acids, epithelium, extractive matter, and a certain 
amount of salts. If the salts predominate, the concretion 
belongs to the second class. 

These concretions occur for the most part in the sebaceous 
glands : they are essentially identical with the false encysted 
tumours formerly described, which are formed by an accumu- 
lation of the secretion in an occluded gland, and are distin- 
guishable from them only by their more solid contents. 

2. The secretion of the gland may deviate from the healthy 
standard, and contain an excess of earthy salts ; in this case 
precipitates will be formed which, on drying, will be gradually 
converted into stony concretions. 

The following may serve as illustrations of concretions in the cuta- 
neous glands. A concretion of the former sort, analysed by Fr. von 
Esenbeck,* consisted of a soft mass, which when dried by exposure to 
the air, formed a yellowish white powder. On triturating it with 
water, a milky liquid was produced which, after standing for several 
days, did not putrify, and which did not coagulate on boiling, but was 
precipitated by acids, corrosive sublimate, and infusion of galls. It 
consisted of : 



Solid fat. . 


24.2 


Alcohol- extract with a trace of oil. 


12.6 


Water- extract. .... 


11.6 


Albumen (cells ?). 


24.2 


Carbonate of lime. 


2.1 


Phosphate of lime. 


20.0 


Carbonate of magnesia. 


1.6 


A trace of acetate and hydrochlorate of soda, 




and loss. 


3.7 




100.0 



A concretion of the second kind formed in the scrotum, and analysed 



* L. Gmelin, n. 2, 1397. 



CONCRETIONS IN THE PARENCHYMA. 383 



by myself, is described in the explanation of Plate x. fig. 2. It con- 
sisted chiefly of calcareous salts. 

In these two cases, although it was not strictly proved that the con- 
cretions actually had their seat in the cutaneous glands, and not in the 
adjacent parenchyma of the skin, yet the former is the more probable. 

With the concretions already considered, we must associate 
others in which the organs yielding the secretions from which 
the concrements are formed are themselves morbid epigeneses. 
To this class belong the ossified encysted tumours mentioned 
in p. 255, where the epidermic or epithelial cells, which invest 
their walls or fill their interior, become incrusted by the depo- 
sition of calcareous salts, and, adhering together, form a con- 
cretion; and the cases in which cholesterin occurs in solid 
masses as a cholesteatoma. Moreover, the reported ossifica- 
tions of many entozoa — of hydatids, the trichina spiralis, &c, 
of which we shall speak presently — belong to this category. 

SECOND CLASS. 

CONCRETIONS IN THE PARENCHYMA OF ORGANS. 

Concretions not only occur in the glands and their excre- 
tory passages, but frequently also in the parenchyma of organs. 
These concretions are generally formed in accordance with the 
same principles and in the same manner as those already 
considered, but they do not exhibit so great a diversity, since 
the mother-liquids from which they are formed almost always 
present the same, or very similar chemical properties. Their 
physical properties exhibit great variations. When they occur 
in small quantity, they form extremely fine precipitates, which 
are generally only visible through the microscope, and appear 
as incrustations of foreign bodies or of organized tissues ; col- 
lected in larger masses, they form more or less isolated, and 
more or less solid portions — cretaceous masses, stones ; or 
they become as it were, fused into the organized portions, and 
form the so-called ossifications. All these distinctions and 
terms are, however, very indefinite, since they are only 



384 



PATHOLOGICAL EPIGENESES. 



based on external, and for the most part, fortuitous and 
unessential characters. The manner in which these concretions 
are formed being different in individual cases, it is not easy to 
deduce any general law on the subject ; however, in most cases 
the following remarks will be found to approximate tolerably 
closely to the truth. 

All the vascular tissues of the body are infiltrated by a 
fluid which proceeding from the vessels, and consequently 
from the blood, is being continuously renewed, since a portion 
is being continuously removed by the lymphatics, and further, 
because it is subjected to a continuous metamorphosis of its con- 
stituents by endosmosis with the contents of the vessels. To this 
fluid we may apply the term general nutrient fluid, although 
it is not always the same, but exhibits many differences, not 
only in different parts of the body, but also in the same part 
at different times. In general this fluid resembles the liquor 
sanguinis, and its changes are principally only qualitative. 
Some of its constituents under certain conditions become 
insoluble, and separate as precipitates ; these most commonly 
are the earthy salts — the phosphate and carbonate of lime, 
ammoniaco-magnesian phosphate, carbonate of magnesia, and 
silica ; more rarely, the salts soluble in water — chloride of 
sodium, phosphate and sulphate of soda, and sulphate of lime ; 
fats — as for instance, cholesterin, and very rarely, some other 
salts of difficult solubility in water — as urate of soda. The 
conditions which must be fulfilled in order to give rise to the 
separation of these substances from the general nutrient fluid, 
are identical with those already described in our remarks on 
the individual precipitates. It is, however, very difficult in 
individual cases, to recognize the acting causes. One frequent 
cause is an extraordinary relative augmentation of certain 
substances in the blood, as when concretions are formed not 
only at isolated spots, but in considerable number, and over 
a great part of the system, as, for instance, in the extensive 
ossification of the arteries, so commonly observed in aged 



CONCRETIONS TN THE PARENCHYMA. 385 



persons. In such cases we can easily trace the formation of 
concretions to a general disposition or diathesis. 

Depositions of this nature form precipitates, or incrus- 
tations, or (where they occur in large masses) ossifications; 
we use the word in the popular sense, and mean only to 
imply that organized tissues become surrounded, enclosed, 
and thus, in a manner, petrified : it is very rarely that they 
form isolated calculi. They may occur in all vascular organs 
of the body, and in morbid fluids, as for instance, pus. 

For the special relations of these concretions in individual organs, we 
must refer to the second volume. In the present place we shall only 
give one or two illustrations by way of showing how their chemical com- 
position varies in different cases. 

Thus twelve concretions found in pus taken from the pleural sac of a 
man aged sixty- six years yielded :* 

Phosphate of lime. . .49.1 

Carbonate of lime. . .21.1 

Insoluble mucus (modified protein ?) 27.8 
Fat. . . . .1.8 

Soluble salts. . . .0.2 

100.0 

In this case the concretions lay perfectly free in the fluid, and were 
only united by a mucoid mass. 

Examples of incrustations of this kind are very frequent. To this 
class belong the depositions which are not unfrequently met with in 
the choroid plexus of the brain, consisting of round microscopic cells, 
coated with phosphate and carbonate of lime.f When occurring in large 
masses, these incrustations resemble ossifications in the cellular tissue, 
the muscles, the biliary ducts, and especially in the heart and arteries. 
The following examples will serve to give an idea of their chemical 
composition : 

1 2 3 

Areolar tissue yielding gelatin on boiling. 68 26 — 
Carbonate of lime. . . 8 23 a trace 

Phosphate of lime. . . . 24 51 80 

Ammoniaco-magnesian phosphate. . — — 20 

100 100 100 



* Prus— Valentin's Repertorium, 1837, p. 118. 

t Henle's Allgem. Anatomie, p. 10. 

VOL. I. C C 



386 



PATHOLOGICAL EPIGENESES. 



1 . Concrement in the muscles of the thigh of a man, analysed by 

Lassaigne, (L. Gmelin, n. 2, 1367). 

2. Annular ossification of the tricuspid valve, (Walchner, ditto). 

3. Pulmonary concretion analysed by Henry, (L. Gmelin, n. 2, 

1370). 

In the above cases the earthy salts predominate : whether there exist 
concretions in which, as Boudet supposes, the soluble (namely the soda) 
salts form the principal ingredient, must still remain questionable. 

There are still two kinds of concretions occurring in the parenchyma 
of organs, presenting distinct chemical characters : 

1. The depositions of cholesterin which are of tolerably frequent 
occurrence in the arterial tissue of aged persons.* The diagnosis of 
these depositions is very easy, being based on their seat (the arterial 
walls) and on the well-known microscopical and chemical characters 
of cholesterin. Their formation is probably dependant on a great 
excess of cholesterin and serolin in the blood, but the causes are not by 
any means obvious, why this fat is only deposited in particular spots of 
the body and of the arteries, instead of being equably distributed. 
Moreover these fatty deposits sometimes occur in other parts besides 
the arteries, as for instance in obsolete tubercle. 

2. Concretions consisting principally of urate of soda (sometimes with 
a little urate of lime) are deposited in the neighbourhood of the joints 
and sometimes in their interior, in the areolar tissue, and in the tendons of 
gouty persons. They occur as earthy masses of indefinite form and size, 
are very light and porous, and of a yellowish white colour : they are 
smooth to the touch, and may be readily scraped by the knife. The 
following analyses will serve to give an idea of their chemical compo- 
sition : 





1 


2 


3 


Water. , 


8.3 


10.3 


(2.00) 


Animal matter (areolar tissue yielding 








gelatin). . 


16.7 


19.5 


10.34 


Uric acid. .... 


16.7 


20.0 


59.43 


Soda. .... 


16.7 


20.0 


15.09 


Lime. 


8.3 


10.0 


8.25 


Chloride of sodium. 


16.7 


18.0 


5.60 


Chloride of potassium. 




2.2 




Loss. ..... 


16.6 




1.29 




100.0 


100.0 


100.00 



The first analysis is by Laugier, the second by Wurzer (see Berzelius's 
Thierchemie, p. 723), and the third by H. C. van der Boon Mesch, in 



* See Plate x. fig. 1. 



CONCRETIONS IN THE PARENCHYMA. 



387 



Bijdragen tot de natuurkundige Wetenschapen, Deel 1. Amsterdam, 
1826, p. 131. The reader would do well to consult J. Moore, Medico- 
chirurg. Transactions, vol. i. p. 112, &c, where the progressive forma- 
tion of these concretions is explained ; and Lobstein, Compte rendu sur 
les Travaux anatomiques, Strasburg, 1824. 

These concretions may be easily recognized by their exhibiting the 
characteristic reaction of uric acid. Their formation depends on the 
circumstance of there being an excess of urates in the blood, but why 
the urate of soda should, as it were by preference, be deposited at par- 
ticular parts of the body, is by no means clear. 

There is also another mode by which concretions are pro- 
duced within the parenchyma of organs, differing theoretically 
from the preceding, but actually very often associated with it. 
The following observations will serve to explain it. 

It has been already shown (p. 101) that many pathological 
epigeneses arise from a mixed plasma, that is to say, from a 
fluid, which may at the same time serve as the formative 
material for organized and unorganized epigeneses. The 
source of this formative fluid is generally, probably always, a 
fibrinous dropsical effusion, whose fibrin coagulates. In this 
exudation, two formative processes are simultaneously going 
on — an organization of the fibrin, and the formation of con- 
cretions consisting generally of earthy salts. The product of 
this formation consists chemically of two distinct steps, one 
relating to the conversion of the fibrin and its modifications 
into areolar tissue, pus-corpuscles, granular cells, and typhous, 
scrofulous, and tubercular matter ; the other, to the consti- 
tuents of concretions, as the salts of lime and magnesia, the 
urates, fat, &c. The individual constituents of either group 
may assume a vicarious position ; moreover, the whole of the 
first group may assume the place of the second, and con- 
versely the second may replace the first, so that the one is 
subordinate in the same degree in which the other predomi- 
nates. This explains the extreme differences in chemical 
composition, which are observed in this class of concre- 
tions. 

c c 2 



388 



PATHOLOGICAL EPIGENESES. 



As illustrations of their chemical composition, we may refer to the 
urinary and intestinal concretions formerly described (p. 358 and 376), 
which belong to this class, and may add the following analyses : 

12 3 4 

Protein- compounds and water. 35 10 24.3 53.16 

Soluble salts. . . — 4 4.0 — 

Phosphate of lime . 61 30 65.3 43.67 

Carbonate of lime . . 4 54 — 3.17 

Carbonate of magnesia. . a trace — 6.5 — 

Phosphate of magnesia. . a trace — — a trace 

100 98 100.1 100.00 

1 . A concretion from the thyroid gland, (Prout, quoted in L. Gmelin, 

ii. 2, 1370). 

2. A concretion from the thyroid gland of a cretin, (Iphofen uber den 

cretinismus, Dresden, 1817). 

3. A concretion from the pericardium, analysed by Robinet and 

Petroz, (Berzelius, Thierchemie, p. 721). It was formed of 
several thick layers which were covered with earthy, pulveriza- 
ble, verrucose concretions. The organic constituents were partly 
organized (areolar tissue which on boiling yielded gelatin) ; and 
partly unorganized (soluble in liquid potash — fibrin) ; the soluble 
salts consisted of sulphate of soda, with a trace of sulphate of 
lime. 

4. A concretion from the uterine surface of the placenta, analysed by 

Wiggers (Berzelius, op. cit. p. 723). The organic constituents 
were fibrin, with a little fat, areolar tissue, and albumen. The 
water amounted to 7£. 

The morphological relations of these concretions, present 
even greater diversities than their chemical composition : 
they are not merely different in different concretions, but may 
also vary in the same concretion in different stages of its 
development. Sometimes the epigenesis is soft, and the 
organic constituents predominate; we can then discover by 
chemical analysis that there is a considerable increase in the 
salts of lime. In many cases the mass appears as an incrus- 
tation, ossification, or calculus. Illustrations of these forms 
may be seen in the second volume, in the chapters on the 
individual organs. 



CONCRETIONS IN THE PARENCHYMA. 389 



Almost all exudations may, under certain conditions, pass 
into concretions, as in the lymphatic glands, the kidneys, the 
spleen, the lungs, the areolar tissue, apoplectic sacs in 
the brain, scrophulous depositions, tubercles, &c. The con- 
ditions governing these transitions are not clear, but the fol- 
lowing may be provisionally indicated : 

1. Great abundance of calcareous salts in the primary 
exudations, as appears to prevail in arthritic persons. 

2. Subsequent separation of calcareous salts, &c, in the 
manner mentioned in p. 384, at a period when the exudation 
predominates, and is either in the act of development or 
absorption. The insoluble earthy salts remain in both cases, 
w 7 hile the protein-compounds are either entirely or partially 
developed, or dissolved and resorbed. The relation that 
these concretions bear to true osseous formations, deserves 
especial attention. As a rule they have, as we have already 
mentioned, no resemblance to true bone, and the term ossifi- 
cation is therefore very unsuitable and liable to be misunder- 
stood ; still there appear to be cases in which these concretions 
occasionally reach a higher degree of organization, and thus 
form transitions to new formations of true bony substance. * 
The mode of transition is, however, little known, and requires 
more accurate examination. 

Of the works treating especially of concretions, the following, besides 
those to which we have already referred, deserve mention : John, che- 
mische Tabellen des Thierreiches, p. 60 ; Duncan, jun., Edinburgh med. 
and surgical Journal, vol. i. p. 407 ; J. F. Meckel, pathol. Anat. n. 2, 
Gurlt medicin. Vereinszeitung, 1833, No. 31 ; Gluge, mikrosk. Unters. 
Part 1, p. 90, &c. ; Henle, allgem. Anatomie, p. 7, &c. ; Remak, 
Casper's Wochenschrift, 1842, p. 1, &c. 



* See Valentin in his Repertorium, 1836, p. 317, &c. 



390 CHANGES IN PHYSICAL PROPERTIES. 



CHAPTER VI. 

PATHOLOGICAL CHANGES IN THE PHYSICAL PROPERTIES OF 
THE TISSUES AND ORGANS OF THE BODY. 

Hitherto we have, with the exception of the changes in the 
blood, treated only of substances which, either do not occur 
in the normal body, or are at least modified and in different 
combinations — as those presenting themselves in many patho- 
logical conditions. These pathological epigeneses, taken in 
the widest sense of the word, are accompanied by certain 
pathological changes, affecting the physical properties of the 
body. 

These changes are numerous, and extend to all the 
perceptible properties of the tissues and organs of the body, 
most frequently, however, altering their colour, size and con- 
sistence. They seldom occur singly, but generally simulta- 
neously with other pathological changes, which, indeed, give 
rise to them ; it is therefore impossible to separate them accu- 
rately from one another. Their consideration is only so far 
important to pathology, in as much as a description of them, 
and the knowledge of their differences may tend to clear up 
their causes and consequences. But such an attempt would 
at present be accompanied with great difficulties, since the 
causes of these changes are still very little known, and are 
extremely numerous and involved. 

The most important of these changes are the follow- 
ing : 



CHANGES OF COLOUR. 



391 



1. CHANGES OF COLOUR. 

Every part of the body has in its normal condition a spe- 
cific colour which depends upon very different causes — solid 
and fluid pigments — and which may differ considerably within 
certain limits, without being abnormal. But when the change 
in the normal coloration exceeds these limits, it becomes 
pathological; it is, however, neither theoretically, nor prac- 
tically possible to separate accurately these normal and 
pathological alterations. Sometimes these changes are of 
no importance, but in many cases, they afford valuable 
aid in recognizing and judging of other pathological condi- 
tions. 

It is of course necessary to be well acquainted with the 
normal colour of the various parts of the body, in order to 
form a judgment of the changes it has undergone ; and this 
knowledge, at least in reference to minute shades of difference 
cannot be learnt from descriptions alone, but must be sought 
in the frequent observation of nature. 

Colour in most cases depends upon the blood, which circu- 
lates through all the vascular parts of the body ; and the 
changes thus effected are of the highest importance to patho- 
logy. They generally accord with the changes already 
described (p. 83—98) in the quantity and distribution of the 
blood, and appear as increased or diminished blood-colouring 
(paleness, and heightened redness) or as an alteration of the 
normal colour into other shades. 

Abnormal paleness. This, as a general rule, leads to the 
conclusion that there is a diminution of the colouring matter 
of the blood in the part affected ; and may depend upon very 
different causes. 

1. On a contraction of the capillaries, by which the quan- 
tity of the blood-corpuscles, and consequently the intensity of 
the red colouring is diminished. There are many familiar 
examples of this state; as, the paleness of the face, in conse- 



392 CHANGES IN PHYSICAL PROPERTIES. 



quence of emotions of the mind, and the transient deadness 
of the fingers. The diagnosis of this condition may be deter- 
mined by the microscopic investigation of the dead body, by 
which we learn by measurements that the capillaries have a 
smaller diameter than in the normal state. But this process 
presents some peculiar difficulties, which often prevent our 
obtaining the desired result. For during the preparation of 
the parts for microscopic investigation, the blood often flows 
out of the capillaries, which then contract in consequence of 
their elasticity. The diagnosis in the living subject is more 
certain since local paleness, during a state of unchanged 
redness in other parts, allows of our drawing a conclusion 
regarding this condition. 

2. Paleness may depend upon a diminution of the corpus- 
cles in relation to the other constituents of the blood, and as 
they are the conveyers of the colouring matter, a less intense 
redness is naturally occasioned. 

3. Upon a diminution of the colouring matter, or a 
chemical change by which its intensity is diminished, so 
that while the number of the blood-corpuscles remains the 
same, each separate one, or at least, a given number contains 
less colouring matter, than in the normal state. 

The two last causes appear to bear on ansemia, chlorosis, 
and similar conditions, but our knowledge is still so deficient 
on this point, that we must look to chemical investigations 
for affording us some better grounded, and more certain infor- 
mation on the subject. 

It will be clearly seen that the changes mentioned under 
2 and 3, combine with 1, and may occasion in addi- 
tion to a general paleness, a more decided local pallor. 
A limited local, or a generally diffused pallor may be 
occasioned by causes, only taking effect during the last 
moments of life, or even after death. This cadaveric paleness 
is caused by the contraction of the capillaries in consequence 
of their natural elasticity, when the heart's movements have 
ceased, or the blood following the laws of gravitation is poured 



CHANGES OF COLOUR. 



393 



forth, (see the chapter upon the changes of the body after 
death). This gives us no insight into the pathological condi- 
tions during life. 

The paleness, thus elicited by various causes is not always 
purely white, but has frequently a tinge of green, blue, or 
brown ; and this is owing to the tissues themselves not being 
of a pure white colour, and to other faint tints from granular 
or fluid pigments, as bile-pigment, hsemaphaein, &c, (which, 
in a normal condition, are concealed by the deeper colour of 
the blood), now appearing more distinctly ; moreover the blue 
coloration of the veins, which we shall presently notice, con- 
tributes to these results. 

Besides the paleness, which depends upon the blood, other 
causes may induce a pallor in parts which are, normally, 
coloured — as fatty depositions, fatty degeneration of the 
muscles, liver and other organs, coagulated fibrin, tubercular 
matter, especially non-vascular epigeneses, and unorganized 
depositions of the most various kinds. They act in a twofold 
manner, first by compressing the vessels of the part, whose 
normal redness depended upon their quantity of blood, and 
secondly by thrusting a new and faintly coloured mass into 
the original tissue. 

Local pallor is further called forth by a deficiency of 
pigment in parts where in a normal condition it exists, as in 
the skin, the hair, and the eyes in cases of leucosis (Albinos). # 
For further particulars of all these changes of colour, and 
their causes, we must refer to the special part, 

Abnormal redness appears much more frequently than ab- 
normal paleness, and likewise admits of classification under 
different heads, according to its causes ; although it is easier 
to do this theoretically than to decide, with certainty, empiri- 
cally upon any individual case. We may have : 

1. Redness from hyperemia of the capillaries, the charac- 
teristic properties of which have been already described, (p. 86) . 



* See Meckel, Patholog. Anat. n. 2, p. 2. 



394 



CHANGES OF PHYSICAL PROPERTIES. 



The colour is, as a general rule, of a vivid red, and appears 
to the naked eye, on account of the smallness of the capil- 
laries, as if the parenchyma of the part were tinged with 
red ; and it is only by microscopic examination, that the 
colour is seen to resolve itself in red capillaries and colourless 
interstices. # 

2. Redness from venous hyperemia, (p. 85). Here 
there is mostly a bluish red, but sometimes a brownish red, 
or even blackish brown colour exhibited by the dead body, 
frequently changing into a clear red, after prolonged exposure 
to the air. The hyperaemic veins are distinguishable with the 
unaided eye or with a lens, and their interstices appear 
colourless. In this category we have the blue disease, (cyano- 
sis), in which several parts of the body, as the lips, cheeks 
and finger ends, are more or less deeply tinged with a purple 
hue.f 

In both these varieties of abnormal redness from vascular 
hyperemia, the deepened colour may not depend alone upon 
hyperemia of the normal vessels, but may be occasioned by 
newly formed vessels, as in granulations, telangiectases, and 
in encephaloid. 

3. Redness from extravasated blood (p. 89 — 97) is frequent- 
ly associated with that which arises from capillary hyperemia. 

4. Redness from infiltration of dissolved hsematin, (page 
97—8). 

The diagnosis of, and the distinctions between these diffe- 
rent conditions, were so fully discussed in their proper places, 
that nothing further remains to be added. 

I will merely remark, that by changes in the dead body, 
a v state of hyperemia of the capillaries, having existed during 
life, may disappear ; and conversely that venous hyperemia, 
and infiltration of hgematin, which did not exist during life, 

* See Plate h. fig. 1 a, b, 

f See a plate elucidating this point in den chirurgischen Kupfertafeln, 
1820, Plates liii—lv. 



CHANGES OF COLOUR. 



395 



may be called forth, so that in judging of these conditions of 
the dead body, much circumspection should be used. 

In all these cases of increased redness from hsematin, the 
blood may present manifold shades of colour, appearing either 
of a light or dark red, purple, brownish red, of the colour of 
tar, &c, without our being as yet able to give with certainty 
the causes of these changes in every individual case, (see 
p. 61, &c.) Sometimes as in extravasated blood, these 
changes go so far that the red colour entirely disappears, 
and gives place to another tint ; thus extravasated blood 
becomes at times blue, orange, bistre-brown, or even black. 
The little that is as yet known concerning these changes has 
been already mentioned, (see p. 193, &c.) These modifica- 
tions in the hsematin may occur after death, as well as before ; 
and our judgment regarding their causes and importance in the 
dead body, demands the same careful attention that we 
recommended in the case of abnormal redness. 

In addition to the changes of colour already considered, 
there are others, of which the most important are : 

Dark coloration from granular pigment (melanosis) which 
has already been specially noticed, (see pp. 189 and 233). 

Yellow coloration of the tissues, depending as far as is yet 
known upon two very different causes. The most frequent 
form in which it appears is dependant on the bile-pigment, 
(the cholepyrrhin of Berzelius), and occurs to the greatest 
extent in jaundice, when it accumulates in the blood, and 
passes from thence into all the fluid secretions, colouring all 
solid and fluid parts of the body. Thus we find it in the brain, 
in cartilage, bone, nerves, lungs, liver, kidneys, ovaries, &c. ; 
there being different shades of colour, according to the extent 
of the deposited pigment, alternating from pale yellow, to 
yellowish green, or even olive green, or dark blackish tint. 
Under the microscope we sometimes observe that the 
tissues are merely saturated with a yellowish fluid, while at 
other times, we discover firm, granular, accumulated deposi- 
tions of a deep yellowish red colour, between the interstices of 



396 



CHANGES IN PHYSICAL PROPERTIES. 



the primary histological elements of the tissues. Indepen- 
dently of icterus, the elementary cells of the liver frequently 
appear to be tinged yellow, and to be filled, or covered with 
minute deeply yellow granules.* 

The diagnosis of the coloration dependant upon bile-pig- 
ment is easy, and is based upon its peculiar reaction when 
treated with nitric acid (see p. 63) 

Another yellow coloration which appears occasionally in the 
organs, but which is invariably local, depends upon a change 
of the haematin in extravasated blood. It is observed after 
sugillations, pulmonary and cerebral apoplexy, and similar 
morbid processes. 

Green coloration of the tissues is but rarely met with. 
It is sometimes observed in the lungs, the intestinal canal, 
and the muscles. Thus the upper lobe of the left lung of a 
soldier, which was emphysematous and void of blood, appeared 
to the unaided eye of a grayish-green colour. Under the 
microscope, the pulmonary tissue itself was tinged with green ; 
the coloration was, with the exception of a few intensely green 
spots, tolerably regular, did not originate from granular pig- 
ment, and could not be washed off with water. The cause of 
the colour could not be discovered. The same is the case 
with the green coloration occasionally perceptible in the 
intestinal canal. Most of these green tints probably 
belong to the changes in the body after death ; and at present 
we can do no more than hazard a conjecture concerning their 
causes. Many may depend upon sulphuret of iron, which in 
a very finely divided state sometimes exhibits a blackish-green 
colour ; many may originate from the effects of putrefaction, 
with which we are but ill acquainted. Probably many changes 
of this kind depend upon the bile-pigment, which permeates 
the walls of the gall-bladder after death, and spreads itself, by 
imbibition, into the surrounding parts, or even sometimes to a 
considerable distance, as the following case will show. A hawk 



See Plate i. fig. 8. 



CHANGES OF COLOUR. 



397 



that had been dead three days was opened. The muscles of 
the abdomen appeared tinged with green, while those of the 
chest, the extremities, and other parts still exhibited their 
normal colour. Under the microscope the greenish muscles 
and the surrounding tissues appeared saturated with a yellow- 
ish-green fluid, without the presence of any abnormal, granular 
pigment. On the addition of nitric acid, the green changed 
first to blue, then to violet, and lastly to purple and pale red. 
The colouring fluid was, therefore, precisely similar to bile- 
pigment. A closer examination of the abdominal cavity 
showed that the gall-bladder, which was very full, formed the 
central point of coloration. Further investigations must de- 
termine whether this kind of coloration of the dead body is 
seen in man at any distance from, or whether it is confined to 
the immediate neighbourhood of the gall-bladder. 

Blue coloration of the organs is very uncommon, excepting 
in those cases which have been already named, where it 
depends upon venous hypersemia. To this head belong the rarely 
observed cases of coloration of the skin by blue sweat.* As 
yet very little is known regarding the composition of this blue 
pigment, or the causes of its origin. I have several times 
observed, that in microscopic preparations of the different 
parts of the body — as of the human skin, exhibiting roots 
of hair — which had been laid in sugared water between 
cemented glass plates, a very finely granular deposit of a beau- 
tiful blue colour was precipitated, which, however, was yielded 
in too small a quantity to admit of chemical analysis. A fur- 
ther prosecution of this subject may lead to an explanation of 
the blue coloration of the skin, which appears during life. 

Many abnormal colorations depend upon matters which 
have reached the body from without ; in this manner we can 
account for the red bones of animals, which have been fed 

* An interesting case of the secretion of a bile-pigment from the 
skin has been described by Dr. Biichner. — Schmidt's Jahrbucher, 
vol. xxxvi. No. 2. 



398 



CHANGES IN PHYSICAL PROPERTIES. 



upon madder, the yellow colour which the pigment of rhubarb 
yields to many organs, and the ashy gray or olive-green tint 
imparted to the skin by the internal use of nitrate of silver. 
To these may be added accidental, or intentional colourings 
of the skin (tatooing), by means of the penetration or rub- 
bing in of gunpowder. 

For some other cases of such colorations by means of medicines, &c„ 
with notices thereof, see Otto's Lehrb. d. Patholog. Anatomie, p. 34, or 
South' s translation, p. 33. A full enumeration of the different patholo- 
gical colorations which appear in the human subject, may be found in 
Hodgkin's Lectures on the Morbid Anatomy of the Serous and Mucous 
Membranes, vol. i. pp. 297 — 327. 

II. CHANGES ON FORM AND SIZE. 

In a general point of view, the observations already made, 
regarding the changes of colour, may be applied to those of 
size and form. Every organ has in a normal state a certain 
size and form,^but these relations are not so accurately defined, 
but that many individual modifications of both may . appear. 
By disease these deviations may be so far augmented as to 
transfer their consideration to the department of pathological 
anatomy, without, however, enabling us to draw any very 
strictly defined limits between their normal and abnormal con- 
ditions. On dissection, when these modifications are in any 
degree considerable, they are the first to attract the attention 
of the most superficial observer, and hence in pathological 
anatomy they have been regarded before other changes, and 
thus in its infancy usurped a large portion of the consideration 
of this science. The more the science is developed, and its 
attention is directed from the accidental to the essential, and 
the more it seeks to clear up the causes and importance of 
individual changes, the less importance will be given to exter- 
nal modifications. A general consideration of these alterations 
is of very little value to science ; it leads to a mere abstract 
system of arrangement, while the actual significance of the 
changes, the category of their causes and consequences, must 



CHANGES OF FORM AND SIZE. 



399 



vary with almost every individual case. I will, therefore, 
leave a more minute consideration of the subject to the 
special part, and limit myself here to a few general remarks. 

To the department of pathological anatomy belong, as we 
have mentioned, only the higher degree of those changes 
which may be distinguished with certainty from mere physical 
modifications ; but as no strict line of demarcation can be 
drawn between health and disease, it is useless to dispute 
concerning individual cases, as to whether certain changes do, 
or do not, belong to pathological anatomy. 

The causes of these changes, on which as a rule their cha- 
racter depends, are very different, and in a great measure 
unknown ; yet, from what has already been observed regarding 
them, they may be divided into the following groups : 

Many deviations in form and size are congenital. Of these 
some are inherited by children from their parents, and thus 
appear to be inherent in the peculiar properties of the genera- 
tive matter — of the germ — in an extended sense of the word. 
As many species of animals, so are also many races of men 
distinguished both externally and internally by peculiarities 
in the form and size of certain organs of the body. Exam- 
ples of this fact are so numerous, and must be so familiar to 
all, that it would be useless here to adduce any. But in these 
cases, it often happens that it is not possible to decide the 
difference between pathological and physiological deviations. 
(This subject will be more fully treated, under the head of mal- 
formations.) 

Other differences of this nature depend upon abnormalities 
of development. In the foetus and the child many parts are 
relatively larger or smaller, and even of a different form from 
the corresponding organs in adult age. If, now, the subse- 
quent and natural development of these parts be arrested by 
morbid causes, that which was previously normal will appear 
to us as disproportionate to the rest. The special causes of 
this impeded development may be very different, and are for 
the most part still obscure. Examples of such deviations 



400 CHANGES IN PHYSICAL PROPERTIES. 



occur, for instance, in the unusual size of the thymus gland, 
at an age when it is generally reduced to a minimum. In 
the foetus, the left lobe of the liver is proportionately larger, 
and the walls of the heart are proportionately thicker than 
at a subsequent age, and this condition may continue to 
exist as a pathological deviation from the normal type, if its 
further development be arrested. (For further informa- 
tion on this subject, see malformations, and the special 
part.) 

Other changes in the form and size arise from external 
influences of a mechanical nature. We may mention the 
changes in the form^of the skull, which many tribes effect in 
their children by compressing or binding the head in a pecu- 
liar manner; also, the feet of the Chinese, which being 
arrested in their growth by mechanical means, become de- 
formed and contracted ; also, the changes in the thorax from 
tight lacing. By means of tightened bandages and stays, 
especially amongst women of the lower classes, the liver is so 
altered that it often exhibits a permanent ridge or furrow 
impressed upon the surface. The action of these influences 
is that the flow of the blood, and consequently organic epige- 
neses are impeded from pressure on the vessels, and the 
growth thus arrested, while the retrogressive activity of the 
metamorphoses (disintegration and resorption) continue unin- 
terrupted. By these processes even very hard parts of the 
body — as bones — are by degrees modified, while the form of 
the softer parts is quickly and directly changed by such 
influences. 

What has been here mechanically induced through external 
agents, is frequently effected in a natural way by pathological 
changes. Thus by the pressure produced by tumours, aneu- 
risms, concretions, &c, soft organs may be changed in form 
and size, and the harder parts, as bones, gradually destroyed. 
Morbidly formed fibrous tissue presses by its elasticity, or by 
the spasmodic contraction excited by the nerves, on soft organs 
— as the lungs, liver, kidneys, &c, and thus diminishes their 



CHANGES OF FORM AND SIZE. 



volume, and alters their form. In these cases also the action 
of the cause is compounded of several factors, being influ- 
enced by direct pressure on the tissues, the blood-vessels, 
and the nerves. 

Many changes of organs, especially those affecting their 
size, and, less frequently, their form, are dependant upon 
the intensity of their physiological functions, and their greater 
or less activity. By increased activity, the nutrition and growth, 
as well as the bulk of most organs are augmented ; while, on 
the other hand, by decreased activity they remain small, or 
continue to diminish. Thus, for instance, the muscles in- 
crease in volume in proportion as they are exercised. But in 
this case the increased nutrition is not the unconditional con- 
sequence of increased activity ; both are only the final points 
of a series of processes connected together by causes, which are 
as yet but imperfectly known. By increased activity, a greater 
flow 7 of blood — a capillary hyperemia, the cause of which has 
hitherto not been sufficiently explained — is occasioned, attended 
by an augmented secretion of blastema, which induces the for- 
mation of new tissue, and causes a local augmentation. 

Hence w T e must not necessarily conclude that the increase of 
size in a part arises of necessity from its increased activity, since 
every cause which calls forth hyperemia of the capillaries may also 
become the cause of an increase in the part effected. According 
to the different modifications and consequences of hyperemia, 
the increase of volume may also vary in its characters. Thus, 
for instance, venous hyperemia in the soft parts, may 
call forth transient enlargement by the infiltration of serous 
fluid ; indeed, hyperemia may occasion an evanescent 
increase of volume by an augmentation of the mass of 
blood contained in the organ ; as, for instance, in the 
erectile organs — the corpora cavernosa of the penis. But 
capillary hyperemia can lead in a very different manner to 
an increase of volume, and it may do this independently 
of an augmentation of bulk resulting from the increased 

D D 



402 



CHANGES IN PHYSICAL PROPERTIES. 



quantity of blood, by the copious secretion of fibrinous fluid. 
If the fibrin coagulate, a new form of increase of volume is 
called forth. A different one occurs when the exuded fibrin 
acts as a cytoblastema, and passes into persistent tissue, by 
which either a true hypertrophy, or a formation of some kind 
of tumour appears as the final result. But all these pro- 
cesses do not necessarily lead to an augmentation of bulk ; 
and it only requires a slight alteration in the process to induce 
a diminution, rather than an increase of size : as, for instance, 
when exuded fibrin is converted into fibrous tissue, which in 
accordance with its character contracts and diminishes the 
part, as in most cicatrices. We observe, therefore, in many 
morbid processes, first an increase of volume, which subse- 
quently diminishes, and is followed by a contraction of the 
organ attacked, as in Bright's disease of the kidneys. 

In many cases of augmentation or diminution of the bulk 
of an organ, these conditions are extremely complicated, and 
much more conjectural than those already considered ; as 
in the tendency to corpulency (Polysarcia), where there is 
often a very considerable deposit of fat in the form of adipose 
tissue in different parts of the body, as in the Panniculus 
adiposus, (see p. 181). The explanation of this process 
must be gained from a knowledge of the nature of diges- 
tion, which we do not yet possess. It is the same with 
morbid emaciation, which is far from being satisfactorily 
explained by suppressed nutrition, or arrested epigenesis, 
since these explanations themselves need elucidation. 

Hollow organs are the most changeable in relation to form 
and size. They increase by the accumulation of their contents — 
as the stomach by food, and the intestinal canal by gas — de- 
creasing as these are voided. Such an evanescent augmentation 
or diminution may, however, become permanent, if the cause 
continue long ; thus, in great eaters, the stomach may attain 
a considerable size, while in those not taking sufficient nou- 
rishment, the whole intestinal canal may appear permanently 



CHANGES OF FORM AND SIZE. 



403 



contracted ; and in cases in which an artificial anus has 
existed for some time, the portion of intestine below it be- 
comes much narrowed. 

Many hollow organs may entirely or partially disappear, as, 
for instance, the gall-bladder after biliary fistula, with the 
simultaneous closing of the cystic duct. 

As the causes, so also are the results of these changes of form 
and size very different. They depend upon special relations, 
upon the situation and importance of the part affected, on the 
nature of the change, &c. ; so that no general laws regarding 
them can be laid down. Indeed, changes which affect the same 
organ, and arise from perfectly similar causes, are often very 
different in their consequences ; while, for instance, an enlarge- 
ment of the muscles of the arm of a blacksmith is a consequence 
of their increased use, and, so far from being attended with 
evil consequences, is a sign of power and health, if a corre- 
sponding augmentation had occurred in the muscular walls of 
the heart, arising likewise from a continuously heightened 
activity, very injurious consequences, and even death itself 
would, as a general rule, occur. 

We usually designate the diminution and augmentation of the bulk 
of an organ by the terms atrophy and hypertrophy. These names must, 
however, be regarded as nothing more than rubrics under which we in- 
clude a number of changes, which, as we have already remarked, inde- 
pendently of accidental alterations of form, have often very little in 
common. It is of especial importance to the consideration of all these 
changes, accurately to ascertain their causes, to arrange these causes in 
suitable groups, and to estimate, qualitatively and quantitatively, the 
action of each. This is at the present time possible only to a yerv 
limited degree, and must, for the most part, be left to future investiga- 
tors. The literature of these changes is, however, tolerably copious. 
Any one desirous of studying this somewhat unprofitable subject, will 
find a considerable amount of information on atrophy in Otto's Patholo- 
gical Anatomy (p. 23 of South's Translation), and in J. F. Meckell, n. 
1, p. 314 ; in the Treatises of Andral, Lobstein, and Cars well ; and in 
the article " Atrophy," by Canstatt, in Wagner's Physiolog. Worter- 
buch; Regarding Hypertrophy, the reader may consult Otto (p. 25 
of South's Translation); Meckel, n. 1, p. 223; and the Treatises of 
Andral, Lobstein, and Carswell. 

D D 2 



404 



CHANGES IN PHYSICAL PROPERTIES. 



III. CHANGES IN THE CONSISTENCE OF THE VARIOUS ORGANS. 

An importance has been attached to alterations in the con- 
sistence of organs which, as in the cases of change in form 
and size, has, we think, been over-rated. The attempt to take 
a general view of certain conditions of the organs, which in 
regard to their causes, consequences, and importance have 
little or nothing in common — to arrange them as cases of 
induration and softening — is, from its very nature, one likely 
to yield no useful results. The view that we shall take of 
this subject in the following pages must be consequently limited 
to the consideration of certain changes of frequent occur- 
rence. 

By hardening or induration is implied an abnormal increase 
in the consistence of an organ ; this may vary from a scarcely 
perceptible increase of consistence to a degree of stony hard- 
ness. It seldom happens that an entire organ is uniformly 
hardened throughout ; we more commonly find the induration 
limited to particular spots. 

The cause of induration is very different in different cases. 

The consistence of a portion of the body may be increased 
by a deficiency of blood (capillary anaemia), since the solid 
elements of the tissue are better able to retain their original 
degree of firmness, than when much blood is present, 
which, like any other fluid, tends to soften the animal 
tissue. This is frequently the case in the spleen, and 
appears sometimes to occur in the substance of the brain. 
However, the increase of consistence arising from (relative) 
anaemia is always slight ; I do not know of a single instance 
in which a great effect has been produced. 

Fibrinous dropsy is a frequent cause of induration, the 
fibrin coagulating and forming a solid substance, penetrating 
between the histological elements of the tissue, and thus 
increasing its consistence. This induration is naturally the 
more striking in proportion as the normal consistence of the 
part affected is less than that of coagulated fibrin : hence it is 
most marked in porous and spongy organs, as the lungs, 



CHANGES IN CONSISTENCE. 



405 



cellular tissue, &c. In some organs it has received special 
names ; thus in the lungs, it is termed hepatization, because 
to a certain degree it communicates to the pulmonary tissue a 
resemblance to liver. 

Numerous cases of induration are dependant on the forma- 
tion of pathological epigeneses which penetrate between the 
histological elements, and render them firm and resisting. 
This effect may be produced by epigeneses of the most dis- 
tinct kinds, as for instance, tubercle, scirrhus, fibrous struc- 
tures, or concretions (ossifications). Since many of these 
epigeneses arise from coagulated fibrin, one kind of induration 
may gradually vary in its nature, and be converted into 
another. 

Hence it follows that induration is often merely an inci- 
dental consequence of other morbid elementary changes which 
have been already described. The consequences, like the 
causes of induration, differ extremely, in accordance with their 
nature and distribution, and the importance of the organ 
affected. 

Copious information on induration in general, and in individual cases, 
may be found in J. F. Meckel, n. 2, p. 14, &c. ; Andral, op. cit. and 
Bayle's Journal de Med. vol. ix. p. 285. 

The reverse of induration is softening — a rubric under 
which it has been attempted to include all abnormal diminu- 
tions of consistence. 

Theoretically we may distinguish between lesser and greater 
degrees of consistence, although there is no definite line, sepa- 
rating one from the other. 

Softening to a slight degree is often only transitory: it 
generally arises from an excess of fluid in the part, from satu- 
ration of its tissues with serum, or the accumulation of a 
more than ordinary quantity of blood in it. In this way 
many organs lose their normal degree of consistence, and 
become soft and yielding. This arises from causes which 
have been already considered — hyperemia and serous dropsy. 
Hence, it follows that some organs are more liable to this forrr 



406 



CHANGES IN PHYSICAL PROPERTIES. 



of softening than others. Thus the spleen very frequently 
softens, since this organ more frequently than any other 
becomes overloaded with blood. The same is the case with 
the lungs ; moreover the brain whose tissue normally possesses 
but little firmness may, by the addition of much fluid, become 
softer. There are other organs which from their very nature 
are incapable of undergoing softening of this nature, as for 
instance, the bones and elastic tissue. Many of these cases 
are merely transitory, disappearing when the hyperemia 
ceases, or the dropsical fluid is resorbed. 

Higher degrees of softening invariably lead to a partial 
solution and destruction— a death of the affected tissue — or 
rather, they arise from it. We have had occasion to notice 
several of these cases of softening in our remarks on suppura- 
tion, and on the softening of tubercles and of the pseudo- 
plasmata. It is, however, at present hardly possible to take 
a general view of these cases of softening, since their causes 
like their forms are very different, and we are not sufficiently 
acquainted with their various conditions. The only method 
by which we can possibly obtain correct views regarding the 
occurrence of softening, is by endeavouring to work out its 
various conditions, in the same manner as Engel has done, 
in relation to the softening of tubercle, (see p. 287). At 
present, however, scarcely an attempt has been made, and 
since the conditions are very numerous and highly compli- 
cated, there seems to be little prospect of attaining this object 
for some time. It has been attempted to explain individual 
kinds of softening by making their occurrence dependant 
on certain general processes, and thus distinguishing inflam- 
matory softening, softening from gangrene, and softening 
from obliteration of the afferent arteries. Something is cer- 
tainly gained by this, but nothing very important, as long as 
the mechanism and the chemistry of the processes induced, 
are not better known. At present the following observations 
embrace most that is known on this subject. 

Most softenings arise from the deposition in the organism 



CHANGES IN CONSISTENCE. 



407 



of substances from the blood, which take no part, or but a 
small one in the general process of metamorphosis, either 
because, on account of their great size, they cannot be pene- 
trated by the fluids of the body, or because their circulation 
has been entirely stopped by the stagnation of the blood in the 
vessels of the surrounding parts. As in these depositions, the 
separation of decomposed tissue, which is maintained in the 
normal state by means of the circulation and the secretions, 
ceases, these substances undergo further decomposition, and 
extend this process to the adjacent tissues, which they imme- 
diately infect. This term decomposition or putrefaction, is 
a mere illustration of the active cause of softening in these 
cases, which may convey a slight idea of these processes, but 
cannot be regarded as any comprehensive explanation, since 
we have as yet a very unsatisfactory chemical knowledge of 
the conditions of the decomposition of nitrogenous organic 
matter, and the concomitant processes. The same is the 
case regarding the transfer of this process of decomposition to 
the tissues, on which we as yet have no special knowledge. 
It is clear that all depositions and all tissues are not affected 
with equal facility by this decomposing process ; hence, evi- 
dently the reason of the great differences which occur under 
this process in individual parts. An accurate knowledge of 
all similar cases can only be gained, when the decomposition 
suffered by different organic substances, if left unmolested, 
or brought under certain conditions be more accurately studied 
than it has hitherto been. 

To this group belong further all those kinds of soften- 
ing which we have previously included under the general 
term of suppuration — the deposition of fibrinous exuda- 
tions, which pass into unhealthy pus; similar deposi- 
tions of tuberculous, scrofulous, and typhous matter, and 
in part also the softening of cancer. These soften- 
ings have this peculiarity that they are mostly preceded by 
induration, as may be observed in many kinds of inflamma- 
tory softening. The chief condition inducing the process of 



408 CHANGES IN PHYSICAL PROPERTIES. 



decomposition seems to be local interruption of the circula- 
tion, and of the metamorphosis of tissue, as far as is depen- 
dant upon the circulation, that is to say, in relation to 
the removal of decomposed matter, infecting the adjacent 
parts. 

In other cases, the softening originates in extravasated 
blood ; which, when occurring in large masses, seems more 
disposed than any other of the constituent parts of the body 
to undergo decomposition; it influences also the adjacent 
parts, if its products, in consequence of the large quantity of 
the extravasation, or owing to local disturbance of the circu- 
lation, be not carried off, but are able to exercise their 
influence upon the neighbouring tissues. To this head 
belong most cases of inflammatory gangrene. # The blood 
undergoes a peculiar change, being converted into brown or 
blackish clots, in which granules of sulphuret of iron 
sometimes appear. f But the chemist 17 of these changes is 
almost entirely unknown. The modifications of the different 
histological elements in these gangrenous softenings are ex- 
tremely various. 

The soft tissues, as might be expected, are first altered, 
and sometimes wholly destroyed. The areolar tissue is either 
broken up into a fine granular mass, which at first has the 
form of fibrous bundles, or it is gradually softened, so that 
larger portions still exhibit the original contour, after the 
individual connecting fibres have disappeared. The cells of 
adipose tissue disappear, and their contents become mixed, 
as drops of fat, with the surrounding fluid ; and crystalline 
masses of margarin or margaric acid generally occur. The 
primitive bundles of muscles lose by degrees their striated 
appearance,! and at last become changed into a pale, gelati- 
nous mass which for a long period retains the external con- 

* See Wagner's Handwdrterbuch d. Physiologie, vol. 1. p. 340. 
f See Plate ix. fig. 10. 
t See Plate ix. fig. 9. 



CHANGES IN CONSISTENCE. 



409 



tour of the primitive bundles.* Tissues with greater power 
of resistance, as the vessels, elastic tissues, bones, and epi- 
dermis are decomposed at a much later period, or not at 
all. 

Similarly to extravasated blood, other fluids which easily 
pass into a state of decomposition, as urine, intestinal excre- 
tions, &c, may give rise to a decomposition and softening of 
the tissues, when in any manner they are infiltrated into 
them. To this class of softening belongs unquestionably 
another, which depends more upon general than local causes : 
for instance, there are cases, in which the whole mass of 
the blood undergoes a certain change or decomposition, 
which we must designate under the term putrefaction, with- 
out at the present time knowing what are its chemical 
changes. 

The fluids separated from the blood, as the general nu- 
trient fluid, being more or less modified, may induce a decom- 
position and softening of the tissues. Thus in typhus, 
and when the blood is loaded with bile-pigment, (as for 
instance in severe cases of icterus), very extensive soften- 
ing occurs, w 7 hich has been well designated under the term, 
gangrene. This condition is naturally susceptible of the 
most numerous modifications, and it is probable that it 
would ultimately lead to a general softening of the whole 
body, if, as a rule, death did not rapidly ensue. In such cases, 
the changes already begun, progress much more rapidly after 
death, but it is not generally possible to decide from the exami- 
nation of the body, how far this softening had proceeded before, 
and how much had occurred subsequently to death. In a few 
cases, a local softening of a higher degree, appears to be induced 
in the softer parts, by the mere presence of serous fluid. Thus in 
the brain, we sometimes find in high degrees of serous dropsy, 
that the walls of the cerebral ventricles have a pultaceous 
appearance, extending to a slight depth (from half a line to 



* See Plate ix. fig. 8. 



410 



CHANGES IN PHYSICAL PROPERTIES. 



a line). That a naturally soft substance like the brain should 
be gradually softened and decomposed by the long continued 
contact and saturation of so mild a fluid as that of serous dropsy, 
is not improbable, although experience seems to prove that such 
a softening is not perceptible in all cases of hydrocephalus. 
Possibly the softening only occurs when from the presence of a 
very large amount of fluid, or from other causes, the meta- 
morphosis and frequent renewal of matter are arrested ; so 
that these cases also rank under the previously described 
classes of softenings. 

In many cases a softening, or more correctly the death and 
decomposition of organs, may be traced to obliteration, or 
closing of the afferent arteries, as many writers (and amongst 
others Carswell) have correctly stated. But here the closure of 
the arteries does not directly occasion the softening ; it is only 
the result of a series of processes, which finally result in 
softening. The most probable explanation seems to be, 
that by the closure of the arteries in the part affected, the 
necessary renewal of the nutrient fluid, through the afflux of 
arterial blood, is arrested, and that the part thus passes into a 
state of decomposition, which extends to the adjacent structures. 
According to this theory, these cases may also be ranked 
under the head of those previously considered. 

It appears very doubtful whether softening can arise from 
a direct influence of the nervous system, that is to say, diffe- 
rently from the manner in which the latter acts upon the 
vascular system, and indirectly induces softening by means of 
one of the previously mentioned conditions. At any rate it 
is expedient to meet such assumptions with some distrust, 
and only to receive them, when it can be proved that mecha- 
nical and chemical causes are not sufficient to explain the 
case. 

In all these softenings of higher degree, the softening itself 
is properly only a secondary matter — the consequence of de- 
composition, the death of the tissue. Hence the various forms 
of death of the tissues in which no softening occurs, become 



CHANGES IN CONSISTENCE. 



411 



directly associated with those previously noticed. To these 
belong dry gangrene, gradual dessiccation of dead organs 
(mummification), and necrosis of bone. In these cases the 
absence of softening depends partly upon the character of 
the tissue, and partly on external influences, as want of 
humidity. 

For further information on softening in general, see Andral's Patholog. 
Anat., and Carswell, fasc. 5, Softening, and fasc. 7, Mortification. 
For the softening, and gangrenous destruction of the individual organs, 
we must refer to the special part. 



412 COMBINATION OF MORBID CHANGES. 



CHAPTER VII. 

MUTUAL COMBINATIONS OF MORBID ELEMENTARY CHANGES. 

The changes described in the preceding pages do not 
always occur singly ; many sometimes being manifested 
simultaneously in the same, or different parts of the body. 
The recognition of the connection in which they stand to each 
other, forms consequently as important a question as the in- 
vestigation of the individual changes themselves. 

We may pursue the investigation of this combination of 
different changes in two ways. The first is by means of the 
numerical method, which leads to a correct conclusion, in as 
much as it shows the greater or less frequency of the simul- 
taneous occurrence of these changes, but leaves the cause of 
these combinations, and the intimate connection of different 
changes entirely in the dark. The second method endeavours 
to point out the intimate connection of individual changes, 
and thus explain the facts elicited by the first method. In 
our introduction we spoke of the various degrees of impor- 
tance existing between these two methods in their application 
to pathological anatomy. We will here consider the latter 
mode, since, as far as is compatible with certainty, it deserves 
a preference over the former. 

In deciding between those pathological changes which 
occur simultaneously in the same part, and those which affect 
different parts at the same period, we must not lose sight of 
the fact, that here the question relates to the smallest parts 



VENOUS HYPEREMIA AND NERVOUS DROPSY. 413 

visible through the microscope — the elementary parts of 
tissue— and not only to larger masses, as whole organs, or 
those parts that are seen by the naked eye. In the earlier 
ages of pathological anatomy, observations were limited to 
what could be detected by the unaided eye, the consequence of 
which was that changes of whole organs were treated en 
masse, and brought under one category of common names ; 
accurate histological investigations have, however, led to the 
conviction that most of those changes, which were formerly 
regarded as simple, are of a composite nature ; and the combi- 
nations of morbid changes have consequently been studied 
with increased attention, and show us that many which were 
formerly overlooked, are really of the highest importance to 
pathology. It further follows that changes, which are the 
opposite of each other in their nature, may yet co-exist in the 
same organ — as induration and softening, increased redness 
and pallor. 

The connection between co-existing morbid changes may 
be more or less intimate. Many changes of this kind 
stand in the relation of cause and effect : in some the con- 
nection is either very remote, or not to be traced ; we 
might even term it accidental, if we could admit the idea 
of chance in the phenomena occurring in the human orga- 
nism. 

The pathological changes arising from a common cause 
may be ranged in certain groups, of which the following are 
the most important. 

FIRST GROUP. 

VENOUS HYPEREMIA AND SEROUS DROPSY. 

Every venous hyperemia may apparently occasion serous 
dropsy (see p. 40) and hence both changes occur very fre- 
quently in the same organ. We seldom meet with venous 
hyperemia without dropsical effusion, except in cases where 
the hyperemia is so recent and slight that the effused fluid 



414 COMBINATION OF MORBID CHANGES. 

escapes detection on account of its small quantity, or of its 
having been carried off by the activity of the lymphatic vessels. 
We more frequently meet with serous dropsy without venous 
hyperemia. This may arise from the fact that the venous 
hyperemia has already disappeared, while its result — the 
serous dropsy still remains ; or owing to the dropsy having 
originated from some other cause than venous hyperemia, 
(see p. 42). But these causes are still very obscure, and 
venous hyperemia appears to be by far the most frequent 
origin of serous dropsy. This group is limited to these two 
changes, generally speaking the degree of softening produced 
by serous fluid is only slight, but in the brain, a higher degree 
of the same change may be occasioned. 

SECOND GROUP. 

CAPILLARY HYPEREMIA AND FIBRINOUS DROPSY. 

The consequences of these processes form a very compre- 
hensive department, extending over most of the elementary 
changes already considered. The two principal links of this 
department are connected with each other, since fibrinous 
dropsy, as we have already shown, is a consequence of capillary 
hyperemia ; but between them there are so many intermediate 
links, that it appears advisable to separate this department 
into two divisions. 

1 . The province of capillary hyperemia, which is in the 
first place characterized by distension of the capillaries, and an 
accumulation of blood in them, and further by a stagnation 
of the corpuscles, and consequently a local stoppage of the 
circulation (stasis, see p. 88). As consequences of this state 
there may be laceration of the capillaries, and consequently 
extravasation of blood. The latter may undergo the changes 
already described (see p. 93), may be resorbed with or 
without change of colour, or may act as a cytoblastema for 
organized, and a plasma for unorganized epigeneses ; it may 



CAPILLARY HYPEREMIA AND FIBRINOUS DROPSY. 415 



further undergo decomposition, and thus lead to the destruc- 
tion of tissue, and gangrene. With this condition, there usually 
also occurs, (either preceding or accompanying it) , a solution 
of the hsematin, and a saturation of the tissues with it. All 
these changes, although from the nature of the case they 
succeed one another, are yet very frequently simultaneously 
present in the same organ. 

2. The province of fibrinous dropsy. The occurrence of this 
fluid as a consequence of capillary hypersemia, leads us to a 
second very comprehensive series of morbid changes. To this 
class belong all the changes affecting the effused fluid, which 
have been formerly described (see p. 52.) The fibrin may 
coagulate, and thus give rise to false hydatids, apparent serous 
dropsy, induration of the affected organ, &c. Then follow 
the great number of changes which arise from the further 
development of the fibrin — suppuration in the widest sense 
of the word, with all its modifications and forms, the forma- 
tion of granular cells, and ulceration — epigeneses of the most 
varying kind, tumours, hypertrophies, concretions, changes of 
colour, softening, induration, &c. ; in short, almost all the 
above described elementary changes. 

Connected with this subject are two questions, whose 
answers possess a high theoretical and practical interest. They 
are the following : 1 . Is every case of capillary hypersemia 
necessarily succeeded by fibrinous dropsy? And, 2. Does 
every case of fibrinous dropsy necessarily arise from capillary 
hypersemia ? or may it arise in some other manner ? Allu- 
sion was formerly made to these questions, but a perfect 
answer was impossible till the above facts had been indivi- 
dually considered. 

The former question, whether every capillary hyperemia 
must be succeeded by fibrinous dropsy, is answered by 
experience in the negative. We often find the capillaries 
distended and loaded with blood, without being able to recog- 
nize the existence of an increased quantity of fibrinous fluid in 
the surrounding parts, and thus our separation of this depart- 



416 COMBINATION OF MORBID CHANGES. 



ment into two provinces is justified, and the independence of 
the former — capillary hyperemia — established. However, we 
should assign to the above-mentioned experience no more 
value than it really deserves ; it merely shows that all cases 
of this hyperemia are not followed by a considerable secretion 
of fibrinous fluid. The exudation may be very slight, and we 
are altogether without means of distinguishing a small quan- 
tity of a fibrinous fluid yielded by dropsy, from the ordinary 
nutrient fluid pervading the tissues ; moreover, as was stated 
in relation to serous dropsy, the whole or greater part of the 
exuded fluid may be resorbed by the veins and lymphatics. 
Further, in many cases of exudation the fibrin appears to 
undergo a chemical change which hinders it from being 
detected by the ordinary means of recognition ; thus it fre- 
quently becomes converted into a species of mucus. An 
instance of this nature is afforded by menstruation, which 
admits of no other explanation. The blood which is effused 
externally, undoubtedly arises from the ruptured vessels of the 
ovaries, and probably, also, of the Fallopian tubes and the ute- 
rus. Although this blood, when it is effused from the vessels, 
must necessarily contain fibrin, yet generally on its discharge 
this constituent is absent, and the fluid does not coagulate. 
In its place there is mucus, and a larger amount than arises 
merely from the vagina ; I have convinced myself of this fact 
by the observation of a case in which the menstrual blood 
proceeded directly from an inverted uterus.* The fibrin is 
doubtless converted, during the discharge of the fluid, into 
mucus, through certain chemical influences of which we are 
still ignorant, but probably through the influence of the alka- 
lies. This fact elucidates an analogous relation of the mucous 
membrane. Whenever hyperemia exists in this tissue, there 
is thrown off a viscid fluid not containing fibrin ; the only 
exception being in what is termed croupy inflammation. The 
probable explanation of this fact is, that the fibrin of the 

* See R.Wagner's Lehrbuch d. speciell. Physiologie. 2nd Edit. p. 236. 



INFLAMMATION. 



417 



blood-plasma, during its effusion on the surface of the mucous 
membrane, is converted into mucus. Hence I believe that 
all those cases in which, after capillary hyperemia, no fibrinous 
effusion is observed, are rather apparent than actual excep- 
tions to the general rule. 

The second question: Whether every case of fibrinous 
dropsy must necessarily have been preceded by capillary 
hyperemia, or whether it may arise from any other cause ? is 
one regarding which experience is still more at fault. It is 
true that we frequently meet with cases of fibrinous dropsy 
and its consequences, without, at the same time and place, 
observing capillary hyperemia ; but in such cases the hyper- 
emia may possibly have disappeared, whilst its product — the 
fibrinous dropsy — remains. On this point we must still rest 
contented with theoretical speculations which, from their very 
nature, can lay claim only to probability, not to certainty. As 
long as we suppose that the connexion between these two 
processes is the same as we have stated (p. 50), namely, 
that fibrinous dropsy arises from an extravasation of blood 
through the attenuated walls of the capillaries, then it will 
remain probable that every case is dependant on capillary 
hypersemia, till it has been demonstrated that it may arise 
from some other cause. 

The processes occurring in this group are designated in pathology by- 
different names, in part individually, in part collectively. Those most 
in use are ranged under the heads of congestion, stasis, and inflammation : 
they are, however, of little value in pathological anatomy : but pathologi- 
cally considered capillary hyperemia would be a more appropriate term 
than congestion, which may, doubtlessly, lead to an incorrect hypothesis. 

Pathological anatomy can only, in very rare cases, give any explanation 
concerning the presence of a stasis, and that solely where a microscopic 
examination of the circulation in living structures is possible. More- 
over, this does not appear to be the right place to enter upon a discus- 
sion of the causes of the stagnation of the blood, since no very 
satisfactory explanation of this process has been given ; and since, 
in all probability, the views which for the moment seem most correct 
will soon yield to others, in their turn to give place to newer ones. Cri- 
tical surveys of the views entertained on this subject up to the latest 
VOL. I. EE 



418 



COMBINATIONS OF MORBID CHANGES. 



date, may be found in Henle u. Pfeuffer, Zeitschrift fur rationelle Medi- 
cin. Vol. 2. Jahresbericht von Henle.— Wharton Jones's Report on the 
Changes in the Blood in Inflammation. (British and Foreign Medical 
Review, No. 35) — and Spiess, Physiologie des Nervensy stems. Braunsch- 
weig, 1844, p. 269, &c. 

Inflammation belongs as little to pathological anatomy as stasis and 
congestion ; it is only the individual processes, or rather the changes 
effected by the latter in the body, that belong to this department of 
science. But as it is customary to speak of inflammation with reference 
to pathological anatomy, it appears necessary to say a few words as to the 
extent to which we may receive the idea of it. Inflammation is not a 
simple process, but rather the common result of a series of processes, 
standing in connexion one with the other. Such are the processes 
which we have already included under the department of capillary hyper- 
emia and serous dropsy. These processes, however, show themselves 
different in almost every individual case. Sometimes the whole series 
is not passed through, and the process is arrested in its development, 
while in some individual cases those processes which we consider as 
associated with inflammation are changed in the most various ways. 
Hence inflammation is very variable in its manifestations, and it becomes 
almost impossible to fix its real definition, or to determine its limits. 
The same is the case regarding other complicated natural phenomena 
which occur externally to the human and animal organisms ; and it would, 
therefore, be just as great a waste of time for meteorologists to contend 
whether or not we should consider every flash of lightning in a clear sky, 
as a storm, as for us to dispute upon the point whether we dared reckon 
certain processes in the human body as inflammation. Practical medicine, 
in its present condition, endeavours to hold fast to a peculiar idea of in- 
flammation for the sake of its bearing upon therapeutics ; trying, at the 
same time, to include it within definite limits. We will not contest the 
point in this case ; but general pathology and pathological anatomy, 
which have not the same mere temporary interests, should not allow 
such a view to be forced upon them. Yet these sciences will be unable 
to answer satisfactorily the questions of practical medicine, until general 
ideas have been elucidated by another form of language — that is, till 
they have been reduced to their elementary phenomena. 

On similar principles some other questions must be answered upon 
which we have cursorily touched ; as, for instance, the opinion of Engel 
(pp. 289 and 313) and others, that tubercles, and the pseudoplasmata 
generally, are always products of inflammation. The consideration ot 
this view resolves itself into two parts, one of which must be answered 
by pathological anatomy, the other by pathology. In relation to patho- 
logical anatomy, the term inflammation signifies capillary hyperemia, 
with fibrinous dropsy and its results. Here we are led to ask, whe- 



INFLAMMATION. 



419 



ther this appearance occurs in every formation of tubercle ; but a direct 
answer to this question is impossible, since the earliest stage of tuber- 
culous formation is in most cases hidden from our observation. Analogy- 
alone enables us to draw the conclusion, that, as in most other patholo- 
gical epigeneses, this appearance precedes, and seems to furnish matter 
for the new structure, so in the formation of tubercles the same is most 
probably the case. This, however, does not exclude the possibility that 
in many cases, a qualitatively changed, nutrient fluid, even without abnor- 
mal increase — without capillary hyperemia and fibrinous dropsy — may 
directly pass into tubercles. It is the province of pathology to discover, 
whether those appearances generally considered to belong to inflammation, 
and which do not fall under the department of pathological anatomy — 
as disturbances of the nervous system — do, or do not occur in the for- 
mation of tubercles. If even in the course of time science should succeed 
in being able to give an affirmatory reply to these two questions, it must 
still be left to the judgment of the individual physician to decide upon this 
point according to the idea that he attaches to the term inflammation. 
This one example may suffice to point out the principles on which similar 
points must be decided. 

We shall notice, in the special part, the elementary changes 
which occur simultaneously, but which unlike those consi- 
dered above, appear to be accidentally associated together, and 
not connected by one originating cause. 



e E 2 



420 



PARASITES. 



CHAPTER VIII. 

INDEPENDENT ORGANISMS IN THE HUMAN BODY. PARASITES. 

All the pathological formations which have been hitherto 
considered are products of the formative power proper to the 
organism ; however much they deviate in form, they are still 
parts of the body. Contrasted with these, are other forma- 
tions in the human subject, which must be regarded, not as 
parts of the body, but as independent individuals, although 
their presence is more or less due to the condition of the 
organism in which they are found. These independent 
organisms are termed parasites, and they so far have a bear- 
ing on pathological anatomy, that they are, more or less, 
connected with pathological conditions. 

As all self-existing organisms which are found upon the 
earth range themselves in two great natural kingdoms, that of 
plants and animals, so also do these parasites. Hence we 
distinguish parasitic plants, without animal motion, with 
simple organization, developing themselves, and growing after 
the manner of plants ; and parasitic animals which, as re- 
gard motion, organization, and propagation, belong to the 
animal kingdom. But the line of demarcation between 
the two natural kingdoms is so indefinite, that with our 
present means of determination, it sometimes remains 
doubtful whether an organized individual must be regarded 
as a plant or an animal — as, for example, in the case 
of bacillaria, closteria, and other allied species, which some, 
with Ehrenberg, include in the infusoria ; while others, with 
equal propriety, refer them to the vegetable kingdom. This 



NATURE OF PARASITES. 



421 



uncertainty applies also to some rare parasites, as for instance, 
the navicular which appear in human excrements, and the sar- 
cina ventriculi. 

To parasitic formations is superadded a condition, by 
means of which it becomes difficult in many cases to deter- 
mine, not merely to which of the two natural kingdoms 
a structure belongs, but even whether it is to be considered as 
an independent parasite, or only a degenerated portion of the 
body. This, for instance, is the case with the highly curious 
pathological structures which J. Miiller has observed in fishes, 
and has named psorospermia* It is only by future observa- 
tions, carefully conducted with an especial view to the origin 
of these structures, that the question can be decided whether 
they are to be regarded as cells degenerated through morbid 
influences, or as independent (parasitic) individuals. These 
formations have not, as yet, been observed in man, and are, 
therefore, in our case, objects of subordinate interest. But 
even in the human subject there are pathological structures 
respecting which it is questionable whether they are to be 
regarded as independent individuals, or as mere degenerations 
of particles of the body. Thus cancer-cells and other similar 
structures are by many classed with parasites, as indepen- 
dent structures (semi-individual cells). 

It appears to me that the question, " what are parasites ?" is not yet 
ripe for decision, but I venture to predict that a more advanced know- 
ledge will limit the acceptation of parasites to those organic structures 
whose germs have penetrated into the organism from without ; although, 
in order that they may develop themselves, there must prevail not 
merely a general, but often a special pathological disposition of 
the system. This view pre-supposes that parasites never arise by 
equivocal generation, but by propagation alone — a point which is no 
longer doubtful. Of cancer- cells, however, it is more than probable 
that the germs are not necessarily derived from without, and, accord- 
ingly, I cannot regard them as parasitic formations. I will remind 
those who affirm cancer- cells to be parasites, merely because nothing 
like them is found in the normal body, that they must consequently 



* Midler's Archiv. 1841. p. 477, &c. 1842. p. 193, &c. 



422 



PARASITES. 



also consign to the same class the pus- corpuscles which exist in the 
same cases. 

Confining our observations to those formations whose 
parasitic nature cannot be called in question, we are met 
in limine by two points of more than general interest, 
which claim our attention, before entering into a detailed 
account of the individual parasites. They are — 1, the origin 
of parasites; and, 2, their baneful influence on the human 
organism. 

Respecting the origin of parasites, there have existed from 
the most remote periods, when they were first remarked, till 
the present time, two opposite opinions. According to one 
view they are generated, in the same manner as most other 
animals and plants, by propagation from progenitors of like 
species • according to the second view, they originate from 
equivocal generation. That many parasites can and actually 
do arise by descent from parents of a similar kind (by gem- 
mules, seeds, and ova,) is at the present day allowed even by the 
believers in equivocal generation. The controversy hinges 
only upon the question : can some parasites, in certain cases, 
also originate de novo, or are those at present occurring inva- 
riably and in every case derived from parents of like species ? 
A positive reply to this question, based upon convincing 
observations and researches, is as little possible now as at the 
time when Pallas wrote his interesting dissertation upon the 
subject,^ although since that period numerous eminent inves- 
tigators have devoted their attention to the formative relations 
of parasites ; but, nevertheless, it appears to me that a majo- 
rity of important reasons favours the view that at the present 
time no parasites are spontaneously developed, but that all are, 
in some way or other, derived from parents of like species. 

* P. S. Pallas, de infestis viventibus intra viventia. Lugduni Bata- 
vorum. 1760. — " Traditis nunc omnium sententiis de viventium intra 
viventia origine, expositisque argumentis propugnantibus singulas et 
contrariis, cujuslibet erit verosimillimam mente comprobare, donee expe- 
titiienta quse in hac parte maximopere deficiunt, certos nos reddunt," 



EQUIVOCAL GENERATION. 



423 



It is out of the question in this place to submit the doctrine of spon- 
taneous generation to a comprehensive criticism ; and I am satisfied, 
therefore, to give for those of my readers who are not familiar with the 
subject, a brief abstract of the present state of the doctrine, and refer 
those who are desirous of further information to the interesting work of 
Hein.* 

The idea of spontaneous generation is a philosophical necessity. 
All organisms with which we are acquainted, that are now derived 
from parents of like species, must at one time have arisen in another 
manner without parents. Whatever name may be applied to this 
primitive origin, or whatever view may be taken of it, whether it be 
termed creation, or receive any other name, it is in reality spontaneous 
generation, in contrast with derivation from parents. This necessity of a 
spontaneous origin of the organisms at present existing is, moreover, 
daily proved by experience. Geology demonstrates that many, indeed 
the greater number of the organisms now on the earth's surface, did 
not exist at an earlier period, since we find no vestiges of them. Ac- 
cordingly, it is undeniable that spontaneous generation occupies a 
prominent position in the history of the world, as a mode of origin of all 
organisms. The question, therefore, turns only upon this point : 
can existing organisms, which at a former period originated sponta- 
neously, and have subsequently propagated themselves in another 
manner, again arise spontaneously ? or, in other words, is there a 
repeated spontaneous origin of creatures of the same species ? 

Let us now consult experience for materials in order to reply to 
this question. We find that in all cases where opportunity has 
been afforded of tracing, by direct observation, the origin of an 
organism, it has taken place by propagation ; whilst, on the con- 
trary, not a solitary unexceptionable observation of a spontaneous 
origin exists in the records of natural history. Analogy is, therefore, 
completely in favour of the view that propagation is the only manner 
in which existing organisms are engendered. The value of this evidence 
is further enhanced by the history of science. In earlier times it was 
admitted that even the vertebrate animals were produced by repeated 
spontaneous generations ; geese and ducks from barnacles, (Lepas) ; 
the batrachia and serpents from mud ; and still, at later periods, 
insects, as the coprophagi, from dung; and fleas from putrid urine. 
No one, at the present day, doubts that all these animals are generated 
by propagation alone. Indeed, in modern times, chiefly through the 
labours of Ehrenberg, even the generation of infusoria has been limited 
to the propagative system. Analogy would, therefore, lead us to 
conclude that parasites are also produced in this manner alone, The 



* J. A. Hein, die Lehre von der Urzeugung. Halle, 1844. 



424 



PARASITES. 



objections which have been urged against this view, and the arguments 
which have been adduced in favour of a spontaneous production of para- 
sites, rest chiefly on the ground that in many cases the origin of these 
organisms, by means of propagation, is inexplicable ; and is, therefore, 
held to be impossible. But it is overlooked that the assumption of 
their spontaneous origin is in reality merely a formal explanation, which 
leaves us completely in the dark respecting the true reasons and condi- 
tions of their production. Moreover, many of these reasons have lat- 
terly become invalidated by the progress of knowledge, since not 
merely the possibility, but also the reality of their propagation to other 
organisms, and the inducing conditions, have been demonstrated in 
various parasites; and although in this respect at present much 
appears mysterious, yet the numerous experiences of latter years must 
raise a hope in every unbiassed observer, that the further advancement of 
knowledge will clear up the obscurity which at present envelops this 
province, and will establish the origin of all parasites by propagation, 
to the exclusion of spontaneous origin. The prevalence in the belief of 
spontaneous generation was an important obstacle to the progress of 
knowledge, since it hindered accurate investigations regarding the for- 
mative relations of parasites ; and with the general diffusion of the view 
that all parasites originate by propagation, observations concerning their 
actual transference from one individual to another, will, doubtless, also 
accumulate. We shall return to this subject in our remarks on 
the individual parasites. 

We shall now consider the relations of parasites to the 
organisms which they inhabit, and to disease. If we assume 
that parasites are invariably derived from parents of the same 
kind, and are never produced spontaneously, it follows that 
they are never a true product of a disease, and cannot, there- 
fore, originate directly from degenerated particles of the 
body, depraved secretions, &c. It is, however, undeniable 
that morbid changes of portions of the body frequently exer- 
cise a certain influence upon their origin. These changes 
may favour their development, and, indeed, alone render 
it possible, by inducing conditions essential to it; they can 
again prove injurious to it, since they may remove conditions 
necessary to its occurrence. Thus, for example, vegetable 
parasites (fungi) do not in general develop themselves upon 
mucous membranes, until, by morbid processes, a deposit of 
coagulated fibrin, which serves as a bed, has become prepared 



THEIR INJURIOUS EFFECTS. 



425 



for them, and until this exudation has passed into a state of 
putrid decomposition. An abundant secretion of mucus favours 
the development of worms which have entered the intestinal 
canal from without. Some states of the organism, on the 
contrary, disqualify it as a habitation for parasites. Thus, 
most of the entozoa in the intestinal canal are expelled by 
increased peristaltic action ; some fluids of the body, as bile, 
urine, gastric juice, and some medicines, prove deleterious, and 
indeed, fatal to some of them ; inflammation, or at least 
suppuration, may injure, and even destroy them. 

As the organism exerts an influence on the parasites inha- 
biting it, so conversely the latter react upon the organism. 
They frequently prove injurious to the system, either by 
mechanical irritation (even by their mere presence, when 
occurring in large quantity, or by obstructing canals,) or 
by exerting a specific action, possibly by fluids which they 
secrete, or in some other unknown way. This pernicious 
influence of parasites upon the organism — their morbific 
power — varies extremely in relation to different species. 
Whilst some produce scarcely any apparent symptoms, so 
that their existence during life is frequently not ascer- 
tained (as in the case of the acarus folliculorum) , others 
give rise to positive diseases, as the acarus scabiei, 
puleoc penetrans, and filaria medinensis. This subject, 
therefore, allows of no general statements ; and we must post- 
pone the special consideration of the effects which the different 
parasites entail upon the organism, to the descriptions of the 
individual species. The disease which accompanies their 
presence is, however, invariably either an effect of their 
presence, and is called into existence by the influence which 
they exert upon the organism, and by the reaction of the 
latter ; or the development of the parasites is, in the manner 
formerly explained, first rendered possible by the presence of 
a disease : the parasite should never be identified with the 
disease itself. 

We now proceed to the consideration of the separate 



426 



PARASITES. 



species of parasites, with especial regard to those hitherto 
observed in man, although, so far as they serve to elucidate 
the subject, we shall also notice those which occur in animals. 

PARASITES DERIVED FROM THE VEGETABLE KINGDOM EPIPHYTES. 

All the parasitic plants which, up to the present time, 
have been observed in the human organism, belong to the 
lowest forms of vegetation — the algse and the fungi. They 
are all very minute, so that, to the unaided eye the greater 
number are totally invisible, and others are only perceptible 
when accumulated in large masses. In order to recognize 
their peculiar structure, and thus to arrive at a more ac- 
curate diagnosis, the microscope is invariably necessary, 
and very high powers are often required. They are found 
either upon exposed surfaces, namely upon the skin and 
mucous membranes, or floating in the fluids of the body. I 
am acquainted with no authentic case in which they have 
been observed during life in the parenchyma of human 
organs. 

Respecting the origin of vegetable parasites, there are the 
same two different views which have been noticed in relation 
to the origin of parasites generally. Whilst, for instance, 
Kiitzing,* who has devoted much of his attention to the lower 
algae, maintains that their origin, by repeated spontaneous 
generation, is possible, others limit their origin to the mode by 
propagation. Although a positive decision of this disputed 
question may at present be impossible, it nevertheless appears 
to me that there are overwhelming reasons in support of the 
view that they invariably owe their origin to propagation alone. 
These reasons are chiefly founded upon the researches of 
Schwann on fermentation, upon similar investigations of Helm- 
holtz,f and upon others which Dr. Merklein has abundantly 

* Phycologia generalis. Leipzig, 1843. p. 129, &c. ; or his remarks 
in Erdmann's Journal f. prakt. Chemie. 1837. vol. xi. p. 391. 
t Muller's Archiv. 1843. p. 453, &c. 



EPIPHYTES. 



427 



instituted upon this subject, all of which show, that under con- 
ditions which otherwise prove favourable to the formation of 
fungi and algse, these do not present themselves, when the 
possibility of the transference of uninjured germs is precluded. 
Moreover, all the parasites hitherto observed, increase in enor- 
mous ratios by means of gemmules or spores : the latter are so 
infinitely numerous, so minute, and maintain their germinat- 
ing power so tenaciously against the most common exter- 
nal agents, that by means of water and currents of air 
they certainly become universally diffused, and can, there- 
fore, develop themselves wherever they meet^ with favourable 
conditions. That we have hitherto, in most instances, failed 
to demonstrate the origin of fungi by transference of 
germs, can be no argument against this mode of propagation ; 
for, even in the most careful examination, certain fungus- 
spores, whose diameters are sometimes less than the 1000th of 
a line, may, and indeed always will escape the notice even of 
the most practised observer. In some cases the transference 
of parasitic fungi, or of their spores from one subject to another 
becomes facilitated by distinct relations, as immediate contact, 
&c. ; as may occur in porrigo, in some forms of impetigo, 
mentagra, &c. These are the cases which are especially 
regarded as contagious. In general, however, peculiar condi- 
tions appear requisite for the development and increase of the 
transferred germs — conditions which are in general only real- 
ized by pathological relations. It appears, for instance, that 
the surface upon which they are to develop themselves must 
in general, if not always, be in a certain state of chemical 
decomposition (putrefaction or fermentation) ; as, indeed, we 
find that externally to the human and animal organisms most 
fungi are developed only on putrefying substances. Experience 
shows us that parasitic fungi are especially liable to occur on 
foul ulcers, and probably only exist on the skin or mucous 
membrane, in the cases where these are furnished with a 
layer of decomposing exudation. Parasitic plants have so far 
a diagnostic value, that they indicate that a process of decom- 



428 



PARASITES. 



position is going on, however locally circumscribed it may be. 
Hence it follows that they do not become developed at all 
spots on which the germs are deposited ; their growth indi- 
cates a certain morbid disposition. 

This view is opposed by the results of experiments made with the 
view of showing that parasitic plants can be transferred by inoculation 
to apparently healthy organisms, and there give rise to morbid pheno- 
mena : thus, for instance, Hassal* was able to transfer, by inoculation, 
parasitic fungi from diseased to healthy lettuces, in which they produced 
the same disease (softening of the stem). These cases, however, prove 
but little ; they merely show that in some instances the disposition to 
fungoid development need not be great ; and they are, moreover, open to 
the objection that the plants which were inoculated, having, perhaps, the 
same habitat, and living under similar relations, already bore within them 
the morbid disposition. 

The pathological signification of parasitic plants, that is to 
say, their power of engendering disease, appears extremely 
various in different cases. Sometimes through their great 
bulk they may become mechanically injurious, as by obstruct- 
ing canals, &c. ; of this, however, no instance has yet occurred 
in the human subject ; they may accelerate incipient decom- 
position of the secretions, and thus prove chemically delete- 
rious ; in some cases they may destroy or modify histological 
elements, (for instance, hairs). Moreover, it is deserving of 
notice, that, by their tenacity of life, which in many cases, 
especially in some cutaneous diseases, (impetigo and favus) 
defies most chemical agents, they ensure to the concomitant 
affection a very long duration. To animals they are some- 
times more injurious than to man ; in the smaller animals 
they may even, through their bulk, occasion death, by obstruct- 
ing canals, &c.f At all events, the part which these parasitic 

* Froriep's, N. Notizen. Oct. 1843. p. 54, &c. 

f Instances of parasitic plants injurious, and even fatal to animals, 
in consequence of their mass, are already very numerous, and fresh cases 
will almost daily be revealed. Amongst the more important cases in 
which animals have been attacked by vegetable growths, we may place 
those noticed in the following memoirs ; — Regarding the muscardine of 



EPIPHYTES. 



429 



fungi act in the diseases which accompany them, is a question 
which renders more extensive investigations still desirable. 

A classification of parasitic fungi might be carried out accord- 
ing to botanical principles. It would, however, be very difficult, 
since the greatest number show no distinct fructification, and 
the mycelia of most fungi in their early stages of development 
resemble each other in an extraordinary degree. Their elemen- 
tary forms are simple cells, which enlarge by the protrusion 
of new cells, or by prolongation into filamentous structures. 
Their fructification consists of spores which are either free and 
agglomerated into pulverulent masses, or appear enclosed in 
proper fruit-beds (sporangia). 

The numerous experiments which I have instituted, compel me to 
join in the opinion of Kiitzing, who, in his observations on the low 
forms of vegetation, occurring in fermenting fluids, says:* " It is ex- 
tremely difficult to reply to the question : Can these structures be 
arranged into genera and species ? I once attempted this distinction 
at a time when I had examined and observed only a few of these forms, 

the silkworm, see Bassi, del mal del segno, calcinaccio, o moscardino. 2nd 
ed. Milano, 1837; Audouin, recherches anatomiques et physiologiques 
sur la maladie contagieuse qui attaque les vers a soie. Annales des 
sciences natur. t. 8, p. 229 and p. 257. Nouvelles experiences sur la 
nature de la maladie, &c. 

A. Hannover iiber contagiose Confervenbildung an Wassersala- 
mandern, in Miiller's Archiv. 1839, page 338, and 1842, page 72; 
Stilling iiber contagiose Confervenbildung auf Froschen; in Miiller's 
Archiv. 1841. page 279 ; Deslongchamp, sur des moississures de- 
veloppees pendant la vie a la surface interne des poches aeriennes 
d'un Canard Eider. Annales des sciences natur. 1841, t. 14, p. 371 ; 
Klenke, Neue physiolog. Abhandlungen. Leipz. 1843, pp. 1 — 93; 
J. Miiller iiber pilzartige Parasiten in den Lungen und Lufthohlen der 
Vogel, in his Archiv. 1842, p. 198 ; F. J. G. Meyer iiber Schimmelbil- 
dung im thierischen Korper (in the Membrana nictitans of falco nisus) 
in his Neue Unters. aus d. Gebiete d. Anat. u. Physiologie, Bonn, 
1842, p. 34, &c. ; B. Langenbeck, Confervenbildung in dem Nasenaus- 
flusse eines rotzkranken Pferdes. Froriep's N. Notizen, 1841, v. xx. 
p. 58. Confervse do not, however, always occur in the mucus of 
glandered horses; Henle never found them, (Pathologische Untersuch- 
ungen, 1840, p. 69) ; neither was I more successful. 

* ErdmamVs Journ. f. prakt. Chemie, vol. xi. p. 409. 



430 



PARASITES. 



yet, even then, their astonishing variety discouraged me from it." 
This announcement from one who has devoted so much of his atten- 
tion to this subject, applies, I believe, equally to the parasitic forms 
of plants occurring in man and animals. There can be no doubt, that 
here, as well as in the other organized productions of nature, there 
are distinct species which do not, as Kiitzing imagines, pass into each 
other ; but they present such manifold varieties, and the lower grades of 
development of different species so closely resemble each other, that a 
definitive separation of them cannot, for a long time, be contemplated. 
It is, therefore, very questionable whether the division, which some 
have attempted, and which we shall adopt, of human parasitic plants 
into distinct species, will be confirmed by future investigators. With 
respect to the questions, whether definite species of fungi are invariably 
found only in definite forms of disease, or conversely, whether in the same 
forms of disease, different species of fungi can sometimes occur, and 
the same species of fungus in different forms of disease, I believe that 
their reply must be for the present deferred, and that only by the una- 
nimous co-operation of physicians and botanists, we can hope to 
arrive at a safe conclusion. 

The following are the forms which have been hitherto ob- 
served in the human subject. 

I. FUNGI IN HUMAN FLUIDS. 

1. The Yeast plant . Torula cerevism, Turpin; Saccharomyces ; My co- 
derma cerevisice, Desmazieres ; Cryptococcus fermentum, Kiitzing. 

This plant not unfrequently occurs in vomited fluids and 
in faecal evacuations; hence it is principally found in the 
intestinal canal, into which, in the majority of cases, it is 
introduced from without, with fermenting fluids, especially 
beer. It is also possible that it may be developed in this 
locality by morbid fermentation taking place in the stomach 
and intestines, particularly by lactic-acid fermentation, It 
exists also, in the saccharine urine of diabetes mellitus, but, 
in all the cases with which I am acquainted, (and I have 
observed a considerable number) not until after its evacuation 
from the bladder. 

These plants are round or oval corpuscles (cells), varying 
in diameter from the 800th to the 400th of a line, and many 



THE YEAST PLANT. 



431 



having smaller corpuscles in their interior. This is their 
most simple form. They grow by protrusion of gemmules which, 
after some time, attain to the size of the original corpuscle, 
and germinate sometimes on one, sometimes on several spots 
of the primitive fungus-cell. These shoots throwing off new 
gemmules, the yeast plant gradually forms rows of oblong cells, 
connected together like beads. A congeries of such cells 
consisting of from three to five, frequently even more, 
commonly forms one plant. # This peculiar arrangement 
of the cells is characteristic of this plant, and in doubtful 
cases, ensures its diagnosis by microscopic examination. They 
are not acted upon by acetic acid. 

As single cells detach themselves from the parent plant, 
they form new individuals which again pass through the pro- 
cess of development already described. In this manner they 
may increase abundantly. In rare cases a mother-cell enlarges 
and there are generated within it, small granules (sporidia) 
which, after the rupture of the mother-cell, emerge and serve 
as germs for new plants. 

It appears to me that these fungi do not possess any pecu- 
liar pathological value ; at most they serve as an indication 
that fermenting substances containing yeast, have been con- 
veyed into the organism, or, that the animal fluids contain 
elements susceptible of fermentation. In this manner we may 
infer that a specimen of urine in which they occur contains 
sugar. Nevertheless, their presence in this fluid is far from 
a safe indication of a saccharine condition, for I have repeatedly 
observed fungi, more or less nearly resembling the yeast plant, 
in urine which contained no sugar ; as, for instance, several 
times in the urine of an uncleanly prostitute, and likewise in a 
specimen of urine which contained fibrinous coagula corres- 
ponding to the urinary canals. In the latter case, besides 
simple cells, the fungi consisted of elongated, partially rami- 
fying filaments, so that their structure approximated to the 



* See Plate x. fig. 8. 



432 



PARASITES. 



more developed forms of the favus plant. In all these cases 
the fungi undoubtedly did not develop themselves till after 
the evacuation of the urine, and then probably from an espe- 
cial condition of the secretion presenting to them a genial soil 
for their growth. 

Fungi are probably not unfrequent in the fluids of the 
intestinal canal, but they readily escape observation when 
they occur singly, and form minute isolated cells. 

Cases of this kind are specified and described by Bohm,* Henle,f 
myself, Gruby,t and others. There are two totally different classes 
of cases, between which we must discriminate : 

1 . Those in which the whole of the yeast plants have been conveyed 
into the body with fermenting drinks, and have there undergone no fur- 
ther change, but have only passed through it (as in cases described by 
Bohm and Henle). 

2. Those in which the fungi, their single spores having probably pe- 
netrated unobservedly into the body, have become further developed 
and multiplied, in consequence of a special morbid disposition (by the 
formation of lactic acid, (?) and perhaps also of acetic acid (?), cases of 
which have been observed by myself and Gruby). The latter cases 
alone have a pathological signification. 

2. Sarcina ventriculi, Goodsir. 

This parasite has been hitherto found in only a few instances, 
and never except in vomited fluids. In its entire habitus it 
is allied to the species gonium, which although placed by 
Ehrenberg amongst the infusoria, is, however, probably a 
plant. The sarcina forms quadrangular or oblong plates 
varying in diameter from the 100th to the 120th of a line. 
The thickness of the plates amounts to about the eighth of 
their diameter. Under low powers the sides appear straight 
and the angles sharply defined, but under higher powers, the 

* Die kranke Darmschleimhaut in der asiatischen Cholera, Berlin, 
1828, p. 57. 

f Patholog. Untersuchungen, p. 42. 

X Comptes rendus, 1844, t. xviii. p. 586. 



S ARC IN A VENTRICULT. 



433 



sides appear indented, and the angles rounded off. Each 
plate appears divided into four squares (secondary squares), 
by two bands intersecting at right angles in the centre ; each 
of these four squares subdivides in a similar manner, into 
four ternary squares ; and each of these sixteen ternary 
squares appears with stronger powers composed of four 
squares which are in immediate contact.* The cells are of a 
brown colour, and their interstices are transparent. Iodine 
communicates to the sarcina a dark yellow or brown colour ; 
alcohol renders it somewhat shrivelled ; it is not destroyed by 
boiling nitric acid. It propagates by division. Nothing is at 
present known with certainty respecting its primary origin, and 
its pathological indications. 

The sarcina was discovered by Goodsir in a fluid vomited at regular 
intervals by a man ; the fluid was in a state of fermentation, and accord- 
ing to Wilson's analysis contained, besides some hydrochloric and lactic 
acids, a very large quantity of acetic acid.f It has since been observed in 
three cases by Busk .J Whether we place the sarcina with the genus 
gonium in the animal kingdom, or whether we regard it as a vegetable, 
it most probably, like the yeast plant, stands in the most intimate 
relation with chemical decomposition (phenomena of fermentation), 
occurring in the stomach. Although it has been hitherto found only in 
the stomach, yet its germs may have penetrated from without. 

II. PARASITIC FUNGI ON THE HUMAN INTEGUMENT AND ITS 
APPENDAGES. 

Fungi of this nature have, during the last few years, been 
frequently observed in the human subject, and fresh observa- 
tions are being continually made. As a general rule pre- 
senting but few exceptions, they appear incapable of being 
developed immediately on the epidermis, or on the epithe- 

* See Plate x. fig. 11. 

t Edinburgh Medical and Surgical Journal, 1842, vol. lvii. p. 430, 
et seq. with figures. 

X Microscopic Journal, January, 1843. 

VOL. I. F F 



434 



PARASITES. 



Hum of the cutaneous glands, and can take root and multiply 
only when, by peculiar relations, a favourable soil has become 
prepared for them. These conditions are presented by fibri- 
nous effusion of the cutis, the fibrin of which coagulates whilst 
the albumen, together with the other elements, dries and forms 
tenacious masses (crusts). To these, when they have under- 
gone a peculiar chemical decomposition, which is not at pre- 
sent clearly understood, fungus-spores and gemmules seem to 
adhere, and there develop themselves. Uncleanliness appears 
greatly to favour this development. 

That under fixed relations the same definite forms of 
fungus are alone developed, although, no doubt, very different 
species of germs fall upon the skin, need occasion no surprise, 
if we consider that the evolution of fungi is generally confined 
to very decided relations of soil, and that most forms of 
fungus in their lower grades of development, when they exhi- 
bit only a mycelium, resemble each other in an extraordinary 
degree. Under favourable circumstances, by assisting in a 
direct transference of germs from one individual to another, 
the development of these fungi can, at all events, be facili- 
tated ; and thus far, some of these forms can be deemed con- 
tagious ; but the vis contagiosa is very slight, and appears 
to be associated with a completely denned disposition, so that 
in a perfectly healthy individual, the transferred germs of 
most fungi are probably incapable of developing themselves. 
We shall recur to this subject in our observations on the 
separate forms. 

In their elementary form the fungi of this class usually 
consist of simple cells which, like the yeast plant, evolve new 
cells by gemmation : these, again, commonly grow out into 
jointed filaments of varying length, and it is only in rare cases 
that these fungi appear to undergo perfect development, and 
to exhibit decided fructification. Their botanical determina- 
tion thus becomes very difficult. 

The pathological importance of these fungi is in most 



FUNGI IN TINEA FAVOSA. 



435 



cases small ; occasionally, however, they acquire an importance 
from obstinately resisting all efforts to eradicate them ; and in 
certain cases, they appear, by their development, able to 
destroy organized parts of the body, as for instance, the 
hair. In a diagnostic point of view their value is greater, 
since, where they occur in large masses, they are accus- 
tomed to impress upon the pathological change a peculiar 
character. 

The following are the most important of the forms hitherto 
observed. 

1. Fungi in the scrofulous scald-head, (Tinea favosa — 
Poirigo lupinosa—Favus and Alphus : Fuchs). The crusts in 
this disease consist for the most part of fungi, which are 
united by, or rather, are rooted in an amorphous matter, 
(dried fibrinous effusion.) The fungi of favus closely 
resemble yeast plants ; in their most simple form they appear 
as roundish or oval cells which increase by gemmation. The 
gemmules are frequently elongated into filaments, which are 
either simple or ramified. # Acetic acid produces no change in 
these fungi, but renders them more distinct, in consequence 
of rendering transparent the amorphous mass in which they 
are enclosed. 

I am firmly persuaded that in tinea the (scrofulous) exuda- 
tion from the vessels of the cutis, is the primary cause and 
essential condition ; it prepares the bed in which the trans- 
ferred germs are developed. Attempts to inoculate the disease 
by transference of fungi to other parts of the skin of the same 
body, or to other individuals, commonly fail, as has been 
shown by the experiments of Gruby, J. H. Bennett, and 
myself. That the development of the fungi originates within 
the epidermis or beneath it, is improbable : yet the 
germs may gain access to its inferior (most recent) layers 
by means of fissures in it, occasioned by the exudation, 



* See Plate x. fig. 6 and 7. 

F F 2 



436 



PARASITES. 



and thus it might seem as if they had been engendered 
beneath the epidermis. 

The most accurate description of these fungi has been given by Gruby,* 
although they were previously noticed by Schonlein,| and E. H. Fuchs.J 
See also, the memoir of J. H. Bennett.§ 

2. Fungi in the sheath of the hair in cases of menta- 
gra, have been observed by Gruby. They form a layer 
around the root of the hair, between it and the sheath, 
investing it as closely as a glove fits itself to the finger. The 
fungi resemble, generally, those of favus, but their spores 
are not oval, as in that case, but present a roundish appear- 
ance, and the thallus-filaments proceeding from the spore- 
cells, have frequently small granules in their interior. In 
reference to the origin and pathological indication of these 
fungi, no doubt the same holds good, as has been stated in 
relation to tinea. || 

3. Fungi in the interior of the hair roots have been ob- 
served in herpes tonsurans by Gruby and Hebra, and in plica 
polonica by Giinsburg. They are developed in the interior 
of the hair-root, from small round spores ; these soften, ren- 
der the hair brittle, and finally cause it to break off, or to 
fall out.f 

Under this head, we must include the fungi which are 
observed in certain cases upon the skin in gangrsena senilis, 
and upon blistered surfaces a few days before death ; ## also 

* Comptes rendus, July and August, 1841. 

t Muller's Archiv. 1839, p. 82, with figures. 

% Die krankhaften Veranderungen der Haut, Gottingen, 1840. 

§ Trans, of the Royal Society of Edinburgh, vol. xv. Part n. 

|| See Gruby, Comptes rendus, 1842, t. xv. p. 512, where there are 
also laid down distinctions, which I, however, believe to be unessential, 
between this plant, and other parasitic fungi. 

^| See Gruby, Comptes rendus, 1844, t. xviii. p. 583; Giinsburg in 
Muller's Archiv. 1845, p. 34, with figures ; see also the chapter in the 
special part, on the anatomy of the hair. 

** Heusinger, Bericht von der Konigl. zootomischen Anstaltin Wiirz- 
burg, 1826, p. 29. 



FUNGI ON MUCOUS MEMBRANES. 



437 



a case described by Mayer, # in which fungi had developed 
themselves in the external auditory meatus of a girl — an 
observation which is especially interesting from the fact, that 
the fungi attained a much higher grade of development than 
in the cases previously described. 

Fungoid structures have been observed on the integument of animals 
more frequently than on man. In addition to the instances already 
cited, Bennett, (op. cit.), has found upon a domestic mouse, fungous 
structures perfectly similar to those which occur in the tinea favosa of 
the human subject. He also observed fungi upon the skin of a gold 
fish (cyprinus auratus). 

III. PARASITIC FUNGI ON THE MUCOUS MEMBRANES OF THE 
HUMAN BODY. 

These are by no means unfrequent, and in recent times 
have been seen by numerous observers. In essential relations 
they perfectly resemble those occurring on the skin, and they 
appear never to take root on sound mucous membrane, 
but always upon a decomposing exudation from the mucous 
surface. 

We find them in the aphthae of children, and on the 
pseudo-membranes which cover the mucous membrane of the 
mouth and fauces in diphtheritis attacking adults ; in certain 
cases they are found in ulcers of the mucous membrane in 
typhus and other diseases. 

In form they sometimes approximate to the fungi of favus ; 
at other times they differ from them in growing out into 
long thallus-filaments, which at certain parts, commonly at 
their termination, present protuberances in which granules 
(spores) are developed. 

Vide A. Hannover in Muller's Archiv. 1842, p. 281, with figures, 
who also gives the earlier literature of the subject ; also Gruby in the 
Comptes rendus, 1842, t. xiv. p. 634. Respecting the very frequent 
fungoid structures on the mucous membranes of animals, see the above 



* Miiller's Archiv. 1844, p. 404, with plates. 



438 



PARASITES. 



mentioned works. J. H. Bennett once found fungi in the sputa and 
lungs of a man with pneumothorax,* and several times in the black 
matter which invests the teeth and gums of patients in the last stage 
of typhus, (loc. cit.) 

PARASITIC ANIMALS. 

The parasitic animals occurring in the human subject, pre- 
sent in their relations a much greater diversity than the para- 
sitic plants. Attempts have been made to classify them 
according to various arrangements. 

1. According to the parts of the body, and the organs 
which they are accustomed to infest. In this respect a dis- 
tinction is drawn between epizoa (ectoparasites) which live 
upon the surface, and entozoa (entoparasites) , which inhabit 
the interior of the body. This division is, however, some- 
what arbitrary since, for example, the intestinal cavity, which 
lodges by far the greatest number of entozoa, compared with 
the external surface of the body, is undoubtedly and relatively 
internal ; compared, however, with the parenchyma of the 
organs it is relatively external. Moreover, some only of the 
parasitic animals have a definite part of the body or an 
organ for a habitation, out of which they are never, or 
only rarely found, whilst others have a very wide distri- 
bution, and probably in different stages of development can 
exist in the most dissimilar parts. 

2. They have been classified according to their position 
in the zoological system. This classification of parasitic 
animals is the most valuable even for the practical physician, 
since it alone leads to a perfect comprehension of the forms 
and distinctions of the separate species, and since we must 
look exclusively to scientific zoological investigations for 
further information respecting the obscure mode of origin of 
these animals, and their occurrence in the human body. 

3. Parasitic animals may be distinguished into those 



* See Plate x. fig. 12. 



PARASITIC ANIMALS. 



439 



whose special abode, ordained to them by nature, is the 
human or animal body— true essential parasites ; and into 
those, to whom nature has assigned another habitation, and 
which only incidentally, and in consequence of peculiar cir- 
cumstances, occur within the body, and are unable to survive 
there — incidental parasites. 

Animals of almost every class, even vertebrata, as for instance, 
amphibia (toads, frogs, salamanders, blind worms), also in- 
sects, and their larvae, snails, &c, have been occasionally met 
with, forming incidental parasites. Many of the cases 
registered in the annals of science are, however, at least 
doubtful, and some reports of the kind, are evidently founded 
upon false statements, or even intentional deception. 

We shall not at present enter more deeply into the consideration of 
these incidental parasites. With respect to the different species observed 
in separate parts of the body, and the pathological changes elicited by 
them, we must refer to the special part. In this place we shall only 
consider the true parasites, especially those which occur in the human 
subject, citing those which are found in animals, only so far as they 
serve to the elucidation of the cases observed in man. 

The questions regarding their mode of origin, and the pathological 
phenomena occasioned by their presence will be had regard to, so far as 
our present deficient observations allow, partly in our remarks on the 
individual species, and partly in our remarks on special organs, since on 
these points general laws cannot be laid down. Every unbiassed obser- 
ver must arrive at the conviction that the morbific power is very dif- 
ferent in the separate species, and will regard it as a far from com- 
pleted scientific labour to point out, exactly, the extent of this power in 
each individual case. According to the prevailing systems, pathology 
has caused the parasitic animals to perform, amongst the causes of 
disease, sometimes a very subordinate, at other times, a very conspi- 
cuous part. Indeed, animal parasites have been regarded by some as 
the causes of almost every disease. See J. C. Nyander, Exanthemata 
viva in C. Linnsei amcenitates academicee, vol. v. Holmise, 1760, p. 92 — 
105 ; also in recent times F. V. Raspail, Histoire naturelle de la sante 
et de la maladie, &c, Paris, 1843, t. i. p. 285—496, t. n. p. 1—286, 
with numerous figures — a strange mixture of truth and fiction, yet, 
for the critical reader, containing some interesting facts, and profitable 
suggestions for further investigations. The reader may also consult the 



440 



PARASITES. 



work of v. Olfers, which in some respects, however, is becoming a little 
antiquated, de vegetativis et animatis corporibus in corporibus animatis 
reperiundis, P. 1, Berol. 1816, c. tab.* 

I. PARASITIC INFUSORIA. 

In the inferior animals, infusoria very frequently occur as 
true parasites, both on the external surface of the body, and 
in their internal cavities. Thus in the intestinal canal of the 
frog, Ehrenberg distinguished no less than five different 
species of bursaria. The infusoria occurring in the human 
body appear, on the contrary, to be not so much true as 
incidental parasites. The condition most essential to their 
development appears to be a degree, however slight, of putrid 
decomposition, such as occurs normally in feces, and in many 
animal fluids as a pathological phenomenon. Infusoria are 
consequently very frequently seen in faeces, and sometimes 
also in foul and impure ulcers. 

The infusoria which, under these circumstances, appear 
most frequently in the body are vibriones, especially a species 
of them which is met with in almost all putrescent fluids 
containing protein (vibrio prolifer ? Ehrenberg). Seen under 
strong magnifying powers these vibriones form sometimes 
simple, sometimes compound (from two to six) bead-shaped 
globules, ranged upon each other,f and exhibit a very active 
animal motion. By feeding them with carmine, I have some- 
times succeeded in bringing the gastric cavity into view. I 
have frequently, but not invariably found these vibriones in 
faeces, especially in liquid evacuations, also in the pus of 
foul, sluggish ulcers. Donne has found this or another 

* I regret exceedingly that I had not the opportunity of consulting 
the excellent article " Parasiten," by K. Th. v. Siebold in Wagner's 
Handworterbuch der Physiolog. vol. n. p. 641, &c. ; which did not 
reach me till these sheets were printing ; hence, instead of incorporating 
his results in the text, I must content myself with referring to his most 
important conclusions in the notes. 

t See Plate x. fig. 10. 



PARASITIC INFUSORIA. 



441 



species of vibrio (v. lineola?) in the pus of chancres.* 
Of other infusoria, I have sometimes found in faeces 
the exuviae, and less frequently, active specimens of navi- 
cula. Upon foul ulcers and in the pus from them, 
vorticella and also colpoda cucullulus have been occasionally 
observed. 

Donnef asserts that he has found a peculiar infusorium, 
which he names trichomonas vaginalis^ in the vaginal 
mucus of syphilitic females; it is supposed by R. Froriep 
and Ehrenberg to be a species of acarus. I, however, agree 
in opinion with Gluge and Valentin, that probably this ima- 
ginary infusorium is not an animal at all, but separated ciliated 
epithelium from the uterus.^ 

The occurrence in the living body of the infusoria which 
have been described, and of other species which probably will 
yet be occasionally observed, need occasion no surprise, if we 
consider that infusoria generally, and especially the specified 
forms belong to the most abundant of all the lower animals, 
which make their appearance by millions whenever conditions 
favourable for their development are afforded. They have 
little or no pathological importance, and at most serve but to 
show that, where they appear, there exists a putrid decompo- 
sition of the elements of the body to a greater or less extent, 
not otherwise demonstrable by exact means. Donne main- 
tains that the vibriones of chancres (and even the trichomo- 
nas) constitute the true contagion of syphilis, an opinion 
which is directly controverted by the fact, that these animal- 
culae do not exist in the pus of syphilitic buboes, which, 
nevertheless, according to Ricord's experiments, by inocula- 
tion also produce actual chancres. 



* Recherches microscopiques sur la nature des mucus secretes par les 
organes genito-urinaires, Paris, 1837. 
t Op. cit. 

J See Plate x. fig. 9. 

§ Siebold also maintains this opinion, op. cit. p. 660. 



442 



PARASITES. 



Beauperthuys and Adel de Roseville assert that in cancer, as well 
before as after softening, they have invariably found animalculse, and 
believe that to these must be attributed the origin, progress, and fatal 
termination of this disease,* — a view which is undoubtedly erroneous, 
even allowing that infusoria do sometimes occur as incidental parasites 
in cancerous ulcers. Klencke states that he has observed in the human 
blood the appearance of animalcules resembling infusoria, and traces 
their connection with the occurrence of periodical attacks of vertigo. f 
In the blood of animals, infusoria have been often found ; thus proteus- 
like infusoria {amoeba of Ehrenberg) have been seen by Valentin in the 
blood of salmo fario,\ and by Gluge in that of frogs. § How these ani- 
mals gain access to the vascular system, is a point upon which at 
present we can only entertain conjectures, although I have no doubt that 
they penetrate from without, and are not engendered by equivocal 
generation. It is not every form of infusorium, which artificially (by 
inoculation) introduced into the circulation of an animal, develops itself 
further ; this ensues only when the conditions are very favourable for 
their development, which is rarely the case ; otherwise they are very 
soon lost. In this point of view, an experiment I instituted myself 
appears to be worthy of communication. From a full grown cat, about 
one ounce of blood was abstracted, and in the place of it, there were 
injected two ounces of a fluid containing very numerous infusoria. This 
fluid was water in which an ape had been macerated during a period of 
two months ; it contained millions of infusoria which belonged to one 
and the same species ; they were oval, the 200th of a line in length, 
and the 300th in breadth (either a species of monas, or the young of 
cyclidium glaucoma?). Besides these infusoria no solid particles were 
contained in the fluid. After the lapse of twenty-three hours, about 
sixteen grains of blood were drawn from the cat. They contained no 
trace of these infusoria. Two days afterwards the animal was killed, 
and the blood carefully examined ; it contained no trace of infusoria ; 
they had all (notwithstanding that millions had been injected) disap- 
peared without leaving the least vestige. It was interesting to 
observe that, in consequence of the injection (?) the blood of this 
animal presented a very decided increase of its fibrin. Whilst before 
the injection the blood contained in 1000 parts only 1.4 of this consti- 
tuent, two days afterwards the same quantity yielded 6.68 parts. 

* Froriep's Neue Notizen, vol. v. p. 112. 

f Neue physiologische Abhandlungen, Leipzig, 1843/ p. 163, &c. ; 
see also Siebold on this point, op. cit. p. 649. 

\ Midler's Archiv. 1841, p. 435. 

§ Comptes rendus, 1842, 14, p. 1050. 



PARASITIC INSECTS — THE FLEA. 



443 



II. PARASITIC INSECTS. 

Insects have been very frequently observed as incidental 
parasites in and upon the human body ; as the ear-wig 
(forficula auricularia) , the eggs and larvae (maggots) of dif- 
ferent species of flies (sarcophaga carnaria, musca cadave- 
rina, m. Caesar, m. vomitoria, &c), which are sometimes 
found in foul ulcers, even upon the living body. 

To those might be added many other species, whose enumeration in 
this place would carry us too far ; we shall revert in the special part to 
the most interesting of this class of cases. For those who desire to pro- 
secute this subject, the above-mentioned work of Raspail, Histoire natu- 
relle de la sante, &c, offers an abundant fund of information, which, 
however, requires to be very cautiously employed.* 

Of this class the only true human parasites are fleas, 
lice, and bugs. 

a. fleas, pulicina. 

The common flea {pulex irritans) lives upon the skin of 
man, but occasionally forsakes it, particularly in the summer, 
and is then to be found in gardens and woods, in sand, earth, 
&c. The female deposits her eggs in putrid materials, 
manure, saw-dust, decayed vegetable matter, rags, &c. : 
sometimes also under the toe-nails of dirty persons. From 
the eggs, which have the size of a small pin's head, there are 
developed minute apodal larvse, which after ten or twelve 
days become transformed into chrysales. Out of the pupae 
come the perfect fleas which then subsist as parasites on man 
and animals. 

The pathological importance of the common flea is known 
to every one ; whilst piercing the epidermis with its proboscis, 
it effects, by suction, a small extravasation of blood which 
appears as a red point surrounded by a paler red areola. 



* See also Siebold, op, cit. p. 654, 



444 



PARASITES. 



Representations of the common flea may be seen in Duges Annal. 
des sc. natur. lere serie, 27, 147, pi. 4, fig. 1 ; in Raspail, op. cit. 
t. 2, p. 48, &c. ; in Joerden's Entomologie und Helminthologie des 
menschl. Korpers, vol. i. p. 41, taf. 4. The fleas of domestic animals 
(pulex canis, felis, gallinse, &c), which likewise occur occasionally as 
transitory inhabitants of the human skin, are different from the true 
human flea. See also Bouche, Nova acta natur. curios, vol. xvn. 
Part 1, p. 503, and Duges, op. cit. 

2. The chiggo, (pulex penetrans) is a smaller, almost invi- 
sible, black flea, which inhabits South America. The 
female penetrates through the skin of man and the do- 
mestic animals into the cellular tissue of the toes, and there 
deposits its eggs which, if not removed in time, may produce 
very malignant ulcers, and even cause death. 

See Duges, Ann. des sc. nat. 2e serie, 6, p. 129, with figures; Perty 
in the Voyages and Travels of Spix and Martius : Delect. Insect. Brasil, 
p. 34 ; Pohl and Kollar, Bras. vorz. last. Insekten, Wien, 1832.* 

b. lice, pediculina. 

1 . The crab-louse, (pthirius inguinalis, Leach, pediculus 
pubis, Linne.) exists among the hairs around the genitals, and 
in the eyebrows of dirty persons. 

Pale or dirty yellow, reddish brown in the centre, short and broad, 
almost quadrangular, from one half to one line long ; the legs different, 
the anterior pair being for progression (the tarsus with only one joint, 
which prevents the separation of the claw), the four posterior climbing 
feet, (the claws being retractile from the presence of two joints). The 
thorax is broad and not distinctly separated from the abdomen. Repre- 
sentations by Burmeister, genera insector, phthirius, f. 1 ; Denny, Mo- 
nographia anoplurorum Britannia?, p. 9, PI. xxvi. fig. 3 ; Alt, Dissertat. 
de phthiriasi, Bonnse, 1824, 4to. fig. 5. 

2. The common louse (pediculus capitis) exists on the 
hairy parts of the head, and is especially frequent in children. 

The genus phthirius is distinguished from all other species of the genus 
pediculus, by all its limbs being climbing limbs. Whitish, thorax ob- 

* Siebold, op. cit. p. 656. 



THE LOUSE. 



445 



longly quadrilateral ; abdomen larger than the thorax, projecting 
behind in the form of an indented oval point, and having lateral serra- 
tions ; all the segments are edged with black upon the outer border. 
Length of body from -§■ to 1 4- of a line. Figures : Burmeister, Genera, Ped. 
cap. fig. 1, males. Fig. 2, females. Denny, Anopl. Brit. p. 13, pi. 26, 
fig. 2. Alt, de phthir. fig. 2. 

3. The clothes louse (pediculus vestimenti) lives upon 
the parts of the skin which are free from hair, and in the 
clothes of unclean persons. 

It appears by many observers to have been confounded with the com- 
mon or head-louse, from which, however, it is clearly distinct. Its 
entire body is paler, it has a much more slender form, and a more sharply 
defined neck ; its thorax is narrower and shorter ; its abdominal segment 
has an obtuse apex, which is not serrated, and its margins are not so 
deeply indented as in the foregoing species. Length of body from 
1 to 1^ lines. Figures : Burmeister, Genera, Ped. vestim. fig. 8. 
Denny, Anopl. Brit. p. 16, pi. 26, fig. 1. Alt, de phthir. fig. 3. 

4. The louse occurring in phthiriasis (pediculus tabescen- 
tium), is found on persons, suffering from marasmus and other 
diseases, from whom, however, it appears not to be propa- 
gated to healthy persons ; at least this is not constantly the case. 
They multiply very rapidly, and may therefore occur in large 
quantity ; nevertheless we must consign to the region of fable 
the statement of Amatus Lusitanus, who relates that two 
slaves were incessantly occupied in conveying to the sea in 
baskets, the lice which appeared upon the body of their master. 
On account of the rapid increase of these animals, many have 
been and still are of opinion, that they arise by equivocal 
generation. This view, however, is altogether unnecessary 
when we consider the astonishing rapidity and abundance with 
which lice increase by propagation. Indeed, Leeuwenhoek 
has calculated that two female head-lice, which multiply far 
less rapidly than this species, can present in two months a 
progeny of 18000 individuals. 

The pediculus tabescentium is of a pale yellow colour ; the head is 
rounder, and the thorax is larger and broader than in the preceding spe- 
cies ; the abdomen is of the breadth of the thorax, but shorter, narrowing, 



446 



PARASITES. 



somewhat, posteriorly ; the margins not serrated, but only undulated. 
Length of body 1^- of a line. Figures : Alt, op. cit. fig. 4. Also Bur- 
meister, Genera, and Denny, Anopl. Brit. p. 19. This, like all the species 
of lice, has been hitherto found by all trust- worthy observers only upon 
the human skin, at most, in crusts, but never beneath the integument. 
It appears to me very improbable that the cases in which small louse- 
like insects have been discovered in abscesses, &c, beneath the skin, 
(Rust in Bremser, Lebende Wiirmer im lebenden Menschen, p. 55, 
Hufeland's Journal, 1813, Part 3, p. 122, et seq.) belong to this place. 
These were probably acari. See Alt, op. cit. 

Besides the above species of lice, others probably occur 
which are true parasites in relation to domestic animals, and 
are occasionally to be found as incidental parasites on the 
human subject. 

These lice belong to a genus very rich in species — hcematopinus, whose 
generic characters are the following : all limbs have climbing feet, the 
thorax is distinctly separate from the abdomen, and usually much nar- 
rower ; the abdomen is broad, and consists of five or nine rings. See 
Burmeister genera. — Denny, Anopl. Brit. — Rayer, Archives de pathologie 
comparee, t. 1, in several places, — and the two very interesting treatises 
of Gurlt, iiber die auf Haussaugethieren und Hausvogeln lebenden 
Schmarotzerinsekten und Arachniden, in Gurlt and Hertwig, Magaz. 
f. d. gesammte Thierheilkunde, Berlin, 1842, p. 409, 1843, p. I. 

c. bugs, cimices. 

The bed-bug {cimex lectularius) is a well known animal 
infesting beds, &c, which by night perforates the epidermis 
with its proboscis, and sucks the blood of man. 

See figures in Burmeister — and Raspail, t. 2, p. 41, pi. 5, fig. 5 
and 7, &c. 

If we take a comparative review of the human parasites 
belonging to the class, insects, we arrive at the conviction, 
that they arise by propagation, and not spontaneously, 
— a conclusion which, at the present day, scarcely any 
one will question. And although some, as has been men- 
tioned, are still inclined to attribute the origin of pediculus 
tabescentium in certain instances to spontaneous generation, 
yet I entertain no doubt, that even here, future and more 



PARASITIC ARACHNIDA. 



447 



minute researches will point out an origin by propagation in 
all cases. 

For the abundant occurrence and increase of most species of 
lice, certain conditions, as want of cleanliness, &c, appear to 
be necessary; and indeed, sometimes even a certain disposition 
of body, delicate skin, youth, &c. This appears especially 
the case with ped. tabescentium, which as several observers 
attest, never pass to healthy individuals, their occurrence 
always indicating an antecedent morbid character of the fluids. 
Nevertheless upon this subject much still remains to be per- 
fected by future researches. In fleas, on the contrary, the 
incursion appears to be much less restricted to any peculiar 
disposition. 

It is very interesting in a pathological point of view to 
observe how unequally different species of these parasites 
rank as morbific agents. Pulex irritans, pediculus pubis, 
capitis et vestimenti are rather troublesome than dangerous 
guests ; pulex penetrans, on the contrary, always induces 
serious consequences, and sometimes even proves dangerous 
to life. The same holds good regarding ped. tabescentium, 
where it occurs in great abundance, although it is not esta- 
blished, whether its occurrence be the cause, or merely the 
effect of a general disease. 

In addition to the works on this subject already quoted, we may men- 
tion : Nitzsch, uber die Gattungen und Arten der epizoischen Insekten 
in Germar's Magazin der Entomologie, vol. in. Halle, 1818, p. 261. 

III. PARASITIC ARACHNIDA. 

In the class arachnida there are many animals injurious to 
human life by their venom, as for instance, many kinds of 
scorpions and spiders ; these, however, do not bear on the 
present subject. One family of this class, however, that of 
the mites (acarina) comprises several species which infest the 
human subject, and are more or less pernicious. These must 
now occupy our attention. 

They are very minute, almost microscopic animals with dis- 



448 



PARASITES. 



tinct and separate sexual organs ; they live upon, and some- 
times beneath the skin, in abscesses, &c., multiply very 
rapidly, and for the most part, possess a great tenacity of life, 
as may be seen by the following startling examples, which are 
related by Hering. A portion of skin from a recently killed 
mangy horse, was laid in a solution of alum and common 
salt, where it remained perfectly covered during eight or ten 
days ; it was then stretched out and dessiccated in a hot cham- 
ber. A very large number of surviving acari then made 
their appearance. 

A strip of skin from another mangy horse, after having 
lain for several days in a cold place, was macerated during 
four days in an aqueous solution of alum and common salt, 
and afterwards dried. There were found upon it, nearly 
four weeks after the death of the animal, some still surviving 
acari. 

1 . The human itch-mite (acarus scabiei, sarcoptes hominis, 
sarcoptes exulcerans) lives upon persons affected with the 
itch. It is white, very minute (from one tenth to one fourth 
of a line), in the form of a point ; when magnified it presents an 
oval body, which upon its superior (dorsal) surface, presents 
rugous transverse striae, having between them, in the middle 
of the back, mamillary projections. It has no true head, but 
upon the anterior extremity of the body, proboscis-like man- 
dibular organs of roundish somewhat compressed form, which 
are furnished with four hairs or bristles. The point of junc- 
tion of the proboscis with the thorax is continued in a roundish 
channel which descends upon the under side of the thorax, 
almost to its centre. Similar projecting channels proceed 
from the points of insertion of the eight feet. Of the latter, 
the four anterior limbs are inserted into the thorax by the side 
of the proboscis, are jointed, and furnished with hairs and 
bristles, the last joint of each terminating in an adhering disk. 
The posterior legs without adhering disks, terminate in very 
long bristles. The abdomen obtusely rounded off posteriorly 
carries two additional pair of bristles, of which the inner 



THE ITCH-MITE. 



449 



is somewhat the longer. The bases of the extremities, and 
the mandibular organs are of a red brown colour. 

The acarus bores channels, often many lines long, in the 
epidermis of the human skin ; and when these have not 
become destroyed, or obliterated by friction of the clothes, by 
scratching, &c, they may be perceived with the unaided eye, 
and more easily with a lens. Upon certain spots where the 
animal either penetrates deeper in the epidermis and comes in 
contact with the cutis, or where it deposits its eggs (for which 
purpose it usually selects the hair or cutaneous glands), vesi- 
cles and pustules are formed in consequence. The animal 
does not, however, live in these pustules, but usually soon 
abandons them, in order to continue its progress. This 
circumstance must be borne in mind in searching for it ; 
its eggs are frequently seen in the pustules, while the 
animal is more commonly found at the further extremity of 
its burrow. It appears as a small whitish speck, with a still 
smaller brownish point, which depends upon the coloured 
anterior extremities, and mandibular organs, and admits of 
ready extraction with the point of a needle. 

The relation of these acari to the itch has been much 
debated, and opinions are still divided upon some points. 
The following are the principal views that have been brought 
forward on this subject. 

1. The acari are the cause of the itch which is called into 
existence by their presence. 

2. The acari are the effects of the itch ; they arise either 
spontaneously in consequence of conditions established by the 
disease, or they are parasites to whom the possibility of exis- 
tence and propagation is afforded by the presence of the 
itch. 

3. They have nothing at all to do with the itch, and their 
presence in this disease is accidental. 

Although at the present day it is impossible positively to 
establish any one of these views, and as certainly to refute 
the others, yet after an unbiassed examination of all arguments 

VOL. I. G G 



450 



PARASITES. 



and objections, it appears to me that the first of these opi- 
nions is the only correct one. Experiments which have been 
instituted upon the human subject, and in still greater num- 
ber with the perfectly analogous itch-mites of animals, prove 
that the transference of acari is capable per se of producing 
the itch in healthy individuals. If males only are transferred, 
a transient irritation may, indeed, ensue, but no scabious 
eruption, since the transferred individuals cannot multiply, 
and their individual operation, unless very many are trans- 
ferred, is too slight to call forth a perceptible exanthema. If, 
on the other hand, females are transferred, actual contagion 
results. Inoculation with the contents of the itch-pustule 
occasions, at most, local irritation, but no itch (Hering). 
These facts establish, beyond question, that the itch can be 
conditional solely on the presence of the acari. The negative 
proof that there exists no other cause of itch than the trans- 
ference of acari is more difficult. Nevertheless, most of the 
objections which are wont to be urged against this view are 
very easily met. Although acari have not been detected in 
every case of scabies, this partly depends upon the fact, that 
most of the physicians w T ho search for the itch-mite have not 
the tact to discover it, and, therefore, in many cases deny its 
presence where in reality it abounds. Again, the itch-mite 
may be already destroyed by the remedies which have been 
applied, and, nevertheless, new eruptions of pustules succeed, 
since the irritation of the skin, occasioned by the long- con- 
tinued presence of the acari, need not necessarily disappear 
immediately on their removal ; indeed, probably in many cases 
it becomes temporarily augmented by the irritating ointments 
applied. Moreover, it is not to be denied that a cuta- 
neous disease, perfectly similar to the itch, can be produced 
by other causes than the itch-mite. Many questions upon 
this subject still remain, therefore, to be resolved by patho- 
logy. That the itch-mite can be spontaneously produced, as 
Hering conceives, appears to me, from the above-mentioned 
general reasons, to be highly improbable. I believe that 



THE ITCH-MITE. 



451 



whenever these animalcules occur upon the human body, they 
have been transmitted to it from without. The appearance 
of itch-pustules, ulcers, &c, appears produced partly by the 
mere presence of the acari and their mechanical effect, and 
partly by the violent scratching of the patient ; that the 
acari secrete acrid juices, and thus exert a chemical irrita- 
tion upon the skin, is improbable. The more violent 
irritation, which itch-patients suffer by night and in the warmth, 
depends upon the natural habits of the acari ; they are espe- 
cially nocturnal animals, and love warmth, and are rendered 
more lively by it. For this reason the disease is especially 
liable to be caught by sleeping with an infected person. 

The different forms of scabies depend, no doubt, on the 
unequal susceptibility and disposition of the cutaneous organs, 
or upon other external and internal circumstances. If, by 
the destruction (by means of ointments, &c.) of the greater 
part of the animals, the itch is for the present cured, the 
disease may after a few weeks, even without new contagion, 
again break out ; for these acari are remarkably tenacious of 
life, and a few of them or of their ova may have escaped ex- 
termination. The itch-mite, like the chiggo, appears to 
take up its abode upon all (even the most healthy) indivi- 
duals, and to indicate by its presence no special disposition. 
Notwithstanding this, however, certain conditions, especially 
uncleanliness, favour its transference and extension, whilst 
others, as extreme cleanliness, restrict them. 

In order to arrive at a correct apprehension of the relations of the 
human itch-mite, it is essential to have regard to the allied forms of 
acarus which occur on the inferior animals ; the more so, since, in the 
latter, experiments with respect to contagion, can be made much 
more readily than in man. To the most important literature on this 
subject, I therefore subjoin that of the itch-mites of animals. Respect- 
ing human itch-mites, see Stannius das Insekt der Kratze. Medic. 
Vereinszeitung, 1835, No. 29. — Muller's Archiv. 1836. Jahresber. 
p. 228. — Raspail, Naturgeschichte des Insektes der Kratze, aus d. Franz, 
mit Anmerkg. von. G. K. 1835.— Raspail, Histoire natur. de la sante, 
&c. t. i. p. 441, &c. — Duges, Annales des sc. nat. 2e serie. 3. p. 245. 
— P. Gervais, Ann. des sc. natur. 2e serie. 15. p. 9. — Nitzsch Art. 

G G 2 



452 



PARASITES, 



Acarus in Erscli and Gmber's Encyelopadie. Also the following disser- 
tations : E. M. Heyland, de acaro scabiei humano. Berol. 1836. J. A. 
F. Rohde, de scabie et acaro humano. Berol. 1836. C. G. Schwartz, 
de sarcopte humano. Lipsiae, 1837. H. Sonnenkalb, de scabei humana. 
Lips. 1841. G. A. Deutschbein, de acaro scabiei humana. Halis, 1842. 
Upon the acari of animals, see E. Hering, die Kratzmilben die Thiere, 
in Nova acta natur. curios. Vol. xviii. Part n. Hertwig in Gurlt 
and Hertwig's Magazin, f. d. ges. Thierheilkunde, 1835, No. 2 ; and 
Gurlt, in the same periodical, 1843, No. 1, p. 18, &c. 

Besides the true human itch- acarus, those peculiar to animals are 
sometimes communicated to man, and may even occasion a scabious 
disease of the skin, as the acarus infesting the horse (sarcoptes equi), of 
which Hering (op. cit. p. 591) has collected several instances, also those 
of the dog, of the wombat (phascolomys ursinus), of the cat, rabbit, and 
camel ; these are, however, exceptions, and the few recorded cases of 
this kind still require confirmation. 

An acarus, which originally lives upon birds, has been repeatedly 
observed upon the human subject {dermanyssus avium, Duges ; acarus 
gallince, Degeer ; a. hirudinis, Hermann; gamasus maculatus).* This 
animal appears to be always a transitory inhabitant of the human subject, 
and only very rarely to induce pathological conditions (erythema and 
vesicles) . Raspail has described, in detail, an interesting case of the 
kind (Histoire naturelle de la sante\ &c, t. i. pp. 376 and 379) ; 
although he has correctly depicted the acarus in Plate in. fig. 1 — 3, he 
mistakes it for rhyncoprion columbce, Hermann ; whereas it is the acarus 
hirudinis of the same author. 

Amongst the acari, we must doubtless include the animalcules men- 
tioned in our remarks on lice, which have been discovered by some 
observers! beneath the skin, in the interior of the body, in abscesses, &c. 
Although at present they have not been minutely examined, and we 
are, therefore, unable even to fix their species, yet the relations under 
which they have been observed are perfectly analogous to those under 
which Nitzsch (in Ersch and Gruber, Part 1, p. 250), has observed the 
sarcoptes nidulans in birds. This careful observer found in the greenfinch 
(fringilla chloris, Temminck), upon the wing and under the skin of 
the breast several yellow tubercles, varying in diameter from three to 
eight lines, which formed open abscesses, and upon closer examination 
proved to be enormous nests of a species of acarus, and were lined with 
a peculiar yellow membranous crust. They were quite full of oval eggs, 

* See Alt, de phthirias. dissert, fig. 1 ; Gurlt in Gurlt and Hertwig's 
Magaz. fur ges. Thierh. 1843, No. 1, PI. 1, fig. 16, 17. 

f Rust in Bremser, Lebende Wurmer im lebenden Korper, p. 55, &c. 



THE ITCH-MITE. 



453 



intermingled with young just hatched, and when first opened, also with 
old acari. 

In addition to these are a few problematical cases, in which peculiar 
forms of acari have been observed in the human subject. 

Bory de Saint Vincent describes peculiar acari (dtrmanyssus), which 
infested the body of a woman in great abundance, but were not commu- 
nicated to her husband. (Annales des sc. natur. lere serie. 18. p. 125* 
PI. i. fig. 6.) To these are allied the acari observed by Busk, in a pue- 
tule, on the foot of a sailor. (Microscopic Journal. Vol. n.$>. 65. PI. iii. 
fig. 7.) 

We must here also doubtless include the argas persicus, an animal- 
cule which in the Persian town of Miana is an extreme annoyance to 
strangers.* Also the nigua {Ixodes americanus) ,\ The acarus dysen- 
teries, which by early authors^ is stated to occur in dysentery, is pro- 
blematical, and, at all events, is not the cause of this disease. 

2. The acarus of the human hair-sac (acarus come- 
donum ; a. folliculorum, G. Simon ; demodex folliculor. 
Owen; simonea folliculor. P. Gervais). 

This animal varies from the 12th to the 8th of a line in 
length, and from the 30th to the 50th of a line in breadth. Its 
mandibular organs consist of two palpse, which have between 
them a proboscis. They pass immediately into the anterior seg- 
ment, which amounts to about one-fourth of the length of 
the body. On it (the anterior segment) are situate four 
pairs of short, thick feet, each consisting of three parts, and 
furnished at the extremity with three short claws, of which 
one is somewhat longer than the other two. The anterior 
segment has four grooved transverse bands, which unite at the 
middle line in a longitudinal stripe. To the anterior is joined 
the posterior segment. It is longer, rounded off posteriorly, 
and filled with a dark, granular substance. It shows through- 
out its entire length fine transverse bands. This animal 
presents very decided varieties and deviations from the form 

* Fischer, Acad, de Moscow, 1823. 

t P. Gervais, Histoire nat. des insectes. Apteres. T. in. — (Nou- 
velles suites a Buffon). Paris, 1844. p. 247. 

+ Nyander, Exanthemata viva in Linne amcenitat. academ. t. v. 
p. 97. 



454 



PARASITES. 



just described, which are probably connected with different 
grades of development. The form which is probably the 
earliest has only three pair of feet and a very long, slender, 
posterior segment ; then comes the above described form, as 
the most frequent ; subsequently the posterior segment appears 
always to become shorter. 

- The acarus folliculorum very frequently exists in the hair- 
glands of the human subject, on the nose, upper lip, and 
the glands of the hair of the beard ; it is sometimes solitary, 
sometimes ten or more are found in a single gland. It 
seems to possess no great pathological importance, since the 
gland which it inhabits frequently shows not the slightest 
morbid alteration ; probably, however, it may sometimes 
irritate the hair-gland, occasion an increase in the quantity of 
its secretion, and thus favour the generation of comedones. 

I do not entertain the slightest doubt that this animal 
arises, in the usual manner, by propagation and transmission, 
and not by equivocal generation. 

The acarus folliculorum was first observed and described by G. Simon.* 
I have occasionally found it in the perfectly normal glands of the hair 
of the chin in the dead body. See Wilson, in the London, Edin- 
burgh, and Dublin Philosophical Magazine, June, 1844. 

IV. PARASITIC WORMS, INTESTINAL WORMS, HELMINTH A. 

(Entozoa, Enthelmintha, Splanchnelmintha) . 

The intestinal worms which occur in man are representa- 
tives of only a few species of the large class of these animals, 
from which scarcely any living being is exempt ; and a cor- 
rect knowledge of the human entozoa, and of their various 
relations, can only be obtained by likewise studying those 
which occur in animals. I must here also repeat my convic- 
tion that these animals arise solely by means of propagation 
and transmission from without, and that it appears to me the 
duty of science to demonstrate this mode of origin, even for 
the human entozoa, in every individual case. The pathological 



* Midler's Archiv. 1842, p. 218, &c, with numerous figures. 



INTESTINAL WORMS. 



455 



indication of the individual worms is so different, that its 
consideration must be reserved for the description of each. 

The most important works respecting entozoa generally, are : Ru- 
dolphi Entozoorum historia. Amstelod, 1808 & 9. — J. G. Bremser 
Icones helminthum. Viennae, 1 824, fol. — Rudolphi Entozoorum 
Synopsis. Berolini, 1819. The latest comprehensive work is that of 
P. Dujardin, Histoire naturelle des helminthes. Paris, 1845, avec 12 pi. 
(Part of the Nouvelles suites a Buffon). For the human entozoa we can 
especially recommend: Bremser, uber lebende Wurmer im lebenden 
Menschen. Wien, 1819 ; a work which presents accurate descriptions 
and correct representations, with abundant literature, and entirely 
supersedes all preceding works, as those of Brera, Joerdens, &c. For 
the anatomy of the entozoa, see Owen in Todd's Cyclop, of anatomy 
and physiology, art. Entozoa; Schmalz, 19 tabul. anatom. entozoorum 
illustrantes, Dresdse. 

In the classification of the human entozoa, I follow the system esta- 
blished by Rudolphi, and let the false succeed the true, in the form 
of an appendix. 

FIRST ORDER. 

NEMATOIDEA. 
ROUND WORMS, THREAD WORMS. 

1 . The thread or guinea-worm, filaria medinensis, filaria 
dracunculus. This worm consists of a long filament of 
whitish, or sometimes brownish colour, of the thickness of 
pack-thread. It is of equal thickness throughout, and it 
terminates posteriorly, as may be perceived on microsco- 
pical examination, in a curved point. The anterior termina- 
tion appears truncated, with several suckers. In length 
it varies from half a foot to twelve feet. As yet only 
females have been observed ; they are viviparous, and 
contain in their interior such a prodigious quantity of 
young, that some maintain that the worm is not an animal at 
all, but a membranous sheath filled with small worms . 
These young filarise are, according to Duncan, the 57th of an 
inch in length. 

The filaria medinensis is found in the tropical regions of 
the Old World, in Arabia, on the Ganges, on the Caspian Sea, 



456 



PARASITES. 



in Upper Egypt and Abyssinia, but especially in the Dutch 
and English possessions of Guinea, where it is so prevalent 
that it has received the name of guinea-worm ; it likewise 
occurs in some districts of the West Indies and of America, 
and upon the island of Curacoa (where it was probably intro- 
duced by negroes) . It exists in the subcutaneous cellular tissue 
of the human subject, most frequently upon the extremities, 
especially the inferior ; but it occasionally occurs in the 
scrotum and other parts of the body. A man has sometimes 
only one, sometimes several (4, 5, 6 — 15) worms at the same 
time. The symptoms which accompany the presence of this 
parasite in the human subject are very various, being some- 
times unimportant, while they are sometimes so violent that 
a dangerous disease, or even death itself results. These 
are diminished, or totally disappear, if the worm is removed 
by cautious extraction. If it should be ruptured during 
the process, the masses of young contained in its interior 
are discharged into the wound, and occasion unhealthy sup- 
puration. 

Although some celebrated authors are of opinion that these 
worms are spontaneously developed, yet it appears to me far 
more probable that they have passed into the body from 
without; either from the stomach or intestinal canal, into 
which the almost microscopic young have been introduced 
with water, or, which is more probable, that they have made 
their way into the body through the integument, and have 
there further developed themselves. The worm may, appa- 
rently, dwell for a long time in the body without being 
remarked, and not excite attention until after its perfect 
development, when it becomes filled with young, which quit 
the parent animal, and by their great number, and active 
movements, excite irritation in the surrounding parts; or 
until it spontaneously endeavours to quit the body in order to 
deposit its young externally. This slow process of develop- 
ment also explains those cases in which the disease has 
broken out in persons who had quitted, eight or even twelve 



THE GUINEA WORM. 



457 



months previously, the countries in which this worm is 
endemic. 

The representation of the worm by Bremser is incorrect, and inferior to 
that given by Birkmeyer in his Treatise, de filaria medinensis comment, 
propriis observat. illustr. Onoldi, 1838. The older literature is very 
complete in Bremser, p. 194, &c, and some more modern papers are 
referred to in Dujardin, p. 44 ; I may also refer to Bruce and Paton, in 
the Edin. Med. and Surg. Journ. 1806, p. 145, &c. ; to Duncan, in the 
Transactions of the Med. and Phys. Soc. of Calcutta, vol. vn. p. 273 j 
and to Forbes, in the Transactions of the Med. and Phy. Soc. 
of Bombay, vol. i. p. 216. Duncan and Forbes bring forward many 
reasons in favour of the transference of the worm : it appears to be 
communicated from the patient to the attendants, to dogs, and to 
horses. Forbes has kept the young alive in moist earth from 
fifteen to twenty days. In the countries where it is endemic, the mud of 
the pools contains numerous animals resembling the young of the worm. 
It is worthy of remark, that as yet only female filarise have been found 
in the human body. Do females alone, while still young, after their 
impregnation enter the human body because they there find conditions 
favourable to their further development ? Or does the male also penetrate 
into the body, but, on account of its smaller size, and because it furnishes 
no young, give rise to no evil effects, and therefore escape observation ? 
The reply to this and to many other questions respecting the origin and 
indication of this worm, must be left to future researches. 

According to observations collected by Pallas,* it appears that even 
in our latitudes thread- worms (the gordius aquaticus ? which is common 
in stagnant water and moist ground) can in certain cases infest the 
human subject. 

I may here mention the fabulous furia inf emails, which, in northern 
Sweden and Lapland, is stated by Solanderf to fall down from trees 
upon men and animals, and generate a fatal disease. 

2. The filaria oculi humani has on several occasions 
been observed by A. v. NordmannJ in the human eye. 
In one of his cases, Nordmann discovered in the Liquor 
Morgagni of a cataractic lens (extracted by Graefe), which 
he examined half an hour after extraction, two small, delicate 
fllarise, coiled in the form of a ring. Under the microscope, 

* De infestis viventibus intra viventia, p. 11. 
f Nova acta Upsal, Vol. i. p. 44. 

j Mikrograph. Beitriige zur Naturgesch. d. wirbell. Thiere, Berlin, 
1832, Part 1, p. 7, Part 2, Preface p. ix. 



458 



PARASITES. 



one of these worms presented in the middle of its body a 
rupture (occasioned probably by the operating needle), through 
which the intestinal canal protruded ; the other was uninjured, 
and was three-quarters of a line in length. It had a simple 
mouth, without distinct papillae, and a straight intestinal 
canal, which glistened through the transparent skin, and was 
observed to be surrounded by the convolutions of the oviducts, 
and terminating at an incurved anal extremity. 

In another case, one opaque crystalline lens of an old 
woman (cataracta lenticularis viridis, extracted by Jung- 
ken), contained a living filaria five and a half lines in length, 
in the act of casting its skin ; whilst in the other lens of the 
same person no foreign animal body could be detected. 

Gescheidt* likewise discovered in an opaque lens extracted 
by Ammon, three filariae, of which the largest was about two 
lines long. In relation to their length, the animalculae were 
remarkably thin and delicate ; the body was of almost equal 
thickness throughout, but tapering a little towards the head ; 
the tail somewhat club-shaped, and furnished with a short, 
slender, curved point. The mouth was small, almost circular, 
and without papillae; the intestinal canal was of a yellow 
colour, and ran without curvature or dilatation as far as the 
tail, where it terminated in a round opening, which received 
at the same time the excretory duct of the ovaries. The 
ovaries appeared as extremely delicate spiral cylinders, whose 
convolutions accompanied the course of the intestinal canal. 

Whether these filariae occur only in the human eye, and form a distinct 
species, or whether, as seems to me more probable, they can also live 
elsewhere, must be decided by future researches. An explanation of their 
origin is at present impossible from want of experience ; yet, in elucida- 
tion of it, the circumstance that filarise have also been found in the blood 
of living animals, appears to me to be important. 

3. The filaria bronchialis, Rud. (hamularia lymphatica, 
Treutler) has as yet been found only once (by Treutler) in 



* v. Amnion's Zeitschr. f. Ophthalmologic, vol. Hi. p. 436. 



TRICHINA SPIRALIS. 



459 



the enlarged bronchial glands of a cachectic young man. They 
were about an inch long, roundish, blackish brown, some- 
times spotted white ; at one extremity there were two project- 
ing hooks (the external genital organs of the male ?) 

Figured by Bremser, PI. iv. fig. 2. Most probably these worms are 
allied to those which are not unfrequently found in the bronchi and lungs 
of animals belonging to the genus mustela. 

4. The trichina spiralis, Owen, is a microscopic worm 
which has hitherto been only found in the voluntary (striated) 
muscles, and then usually in very great numbers. In such 
cases the muscles appear dotted with minute white spots 
which, under the microscope, represent elliptic cysts, com- 
monly elongated at their extremities ; the long diameter being 
always parallel to that of the primitive fasciculus. These 
cysts, whose long and short diameters are about the 50th, 
and the 100th of a line respectively, constitute the habitation 
of the worm. They are usually so transparent that, under 
the microscope, even without opening them, the animal may 
be recognised in the interior. It occupies about the third 
part of the cavity of the cyst, appears coiled up into a spiral 
of two or two and a half turns, is round and filamentous, 
presents a somewhat truncated appearance at both sides, 
and slightly tapers towards one end. When extended, its 
length varies from one half to one third of a line ; its diameter 
from the 60th to the 80th of a line. Internal organs cannot 
be perceived in it. In general only one worm is contained 
in one cyst, rarely two, and still more rarely three. The 
cysts frequently contain in addition to the worm, deposi- 
tions of calcareous salts, so as to form small granulations 
which grate under the knife. These often conceal the worm, 
which in this case frequently, but not always is dead; if, 
however, the calcareous salts are removed by acetic acid, 
the worm becomes apparent. 

With the exception of the heart, these animals occur in all 
striated muscles. They have been found in persons who 
have died of very different diseases ; moreover, even in some 



460 



PARASITES. 



who, whilst in perfect health and vigour, had been suddenly 
destroyed by mechanical injuries (fracture of the scull). Their 
pathological importance seem, therefore, to be not very great. 
The occurrence of this worm has been, even recently, regarded 
as affording an important support to the theory of sponta- 
neous generation ; although I believe, that ultimately also in 
this case, a transference from without will be successfully 
proved 

The trichina was first discovered in England, and described by Owen.* 
It has been since observed by others, (Farre,t Henley Kobelt,|| 
Bischoff,§ Bowman, &c.) Farre states that he has observed in it an 
intestinal canal with evident walls. On account of its symmetrical form, 
I hold the investing capsule of the worm not to be a secondary cyst 
produced, as in the case of hydatids, by reaction of the organism which 
harbours it, but believe that it pertains to the worm itself, and is the 
result of a kind of metamorphosis of the animals. This view is supported 
by the regular form characterising these cysts, which are elongated and 
terminate in pestle-like extremities. Most trichina?, before they can escape 
from their cysts, undergo the calcareous incrustation already noticed. 
What becomes of those which quit the cysts is unknown. The trichinae 
which Bowman has observed in the interior of the primitive muscular 
fasciculi should be probably here noticed ; possibly the animal after- 
wards becomes larger, and attains to a more developed form of the 
nematoidea. In favour of the origin of a trichinae by transference, it 
may be mentioned that they (probably the same species) have been 
observed also in animals. Diesing has found them in the horse ; 
Siebold in several of the mammalia and birds : I have found perfectly 
similar animals in the peritoneum of an owl, and a few days ago, 
through the kindness of my colleague, Professor Herbst, I observed 
trichinae, completely resembling those occurring in the human subject, 
in nearly all the muscles of a cat. The detection by several recent 
observers of filaria-Uke worms in the blood of different animals, is sugr- 
gestive of their mode of origin. See Rayer, Archives de med. comparee, 
1843, t. i. p. 40 et seq. ; Vogt in Muller's Archiv. 1842, p. 189; 
and Gruby and Delafond in Froriep's N. Notizen, Febr. 1843, p. 231. 



* Transact, of Zoological Soc. vol. i. London, 1835, p. 315 et seq. 

t Medical Gazette, Dec. 1835. 

X Muller's Archiv. 1836, Jahresber. p. 227. 

|| Froriep's N. Notizen, 1840, vol. xin. p. 309, vol. xiv. p. 235. 

§ Medicinische Annalen, vol. vi. p. 232 and 485. 



TRICHOCEPHALUS DISPAR. 



461 



5. The trichocephalus dispar, (trichuris, Roed, and Wagl.) 
or long thread-worm is a thin, filiform animal, varying in 
length from an inch and a half to two inches. It consists 
of a very delicate, capillary anterior portion, which includes 
about two thirds of the length of the worm, and then passes 
rather suddenly into a strikingly thicker posterior extremity. 
It is usually white, although occasionally somewhat coloured. 
The worm has separate sexes, the males and females being 
-essentially different ; and hence the name dispar. The male 
is rather smaller than the female ; its capillary anterior part is 
pointed, the thicker posterior portion is spirally coiled, and 
exhibits on its extremity a long penis (spiculum), invested 
with a proper sheath. In the female the capillary anterior 
portion is longer ; the thicker posterior part being straight, 
and only a little inverted at the extremity ; the penis with its 
sheath is absent. The eggs are oval, with resisting shells, 
and when mature, measure the 40th of a line in length. 

The trichocephalus dispar is of very frequent occurrence 
in the large intestines, particularly in the human csecum ; it 
sometimes occurs in nearly half the subjects examined. Some- 
times it is found alone, at other times in great numbers. It 
firmly adheres by its capillary head to the mucous mem- 
brane. 

The pathological importance of this worm appears slight, 
since it is frequently found in great quantities in persons, who 
during life did not exhibit any symptoms of its presence. 

Bremser, p. 76, PI. 1, fig. 1 to 5. On the anatomy of the tricho- 
cephalus, see Meyer, Beitr. zur Anatomie der Entozoen, p. 4 to 14. 
A similar trichocephalus, apparently the same species, is found in 
swine. 

6. The trichocephalus affinis, Rud. a species otherwise occurring only in 
the ruminantia (of the genera cervus, antilope, ovis and bos) is stated 
to have been once found in the human subject, on a soldier who had 
died in Fort Pitt from angina tonsillaris; this worm was found in 
the left tonsil,* which was tumid and gangrenous. 



* Monthly Journal of Medical Science, 1 842', May. 



462 



PARASITES. 



7. The spiroptera kominis, Rud. is a small, delicate, spirally coiled 
worm of white colour, and with separate sexes. The two sexes differ 
in their form and size. The male measures eight, the female ten lines 
in length. The head ends obtusely and has one or two papillae, and 
an orbicular mouth. The body is round, tapering towards both extre- 
mities, especially towards the anterior. In the female the tail is thick 
with a short, blunted point ; in the male, thin, with a tube — probably 
the sheath of the penis. An aliform appendix towards the tail is charac- 
teristic of this animal. 

The spiroptera hominis has hitherto been only found in one instance, 
by Barnett of London, and is stated to have been discharged with the 
urine by a woman. It possesses at all events no great importance. 

Figured by Bremser (PI. iv. fig. 6 to 10) who regards these worms as 
young strongyli. 

8. The strongylus gig as, Rud. is a very large, round 
worm, varying from five inches to three feet in length, 
and from two to six lines in thickness, and, when 
recent, of a blood-red colour. The sexes are separate, 
and differ in form. The male is smaller than the female, 
and tapers somewhat towards both ends. The head is obtuse, 
the mouth orbicular, and surrounded by six minute papillae. 
The body is marked by circular striae, and presents several 
shallow longitudinal furrows. At the posterior extremity, the 
male presents an infundibuliform pouch, from which a very 
slender penis protrudes. The female is larger and has a 
straightly extended and obtuse tail, on which may be seen the 
oblong anus. Its vulva is one or more inches distant from 
the extremity of the tail, according to the size of the indivi- 
dual. The ova are almost globular. 

The strongylus gigas inhabits the kidneys, and the cellular 
tissue surrounding them. It is highly dangerous, and by its 
presence may occasion a total destruction of this organ, or 
even cause death. This species occurs also in several animals — 
the horse, dog, wolf, marten, &c. 

See representations in Bremser, PI. 4, fig. 3 to 5 ; Gurlt, Lehrb. 
der patholog. Anat. der Haussaugethiere, PI. 8. fig. 25 to 28, and Rayer, 
Maladies des reins. 

9. The round worm, ascaris lumbricoides, Linne, is 



ASCARTS. 



463 



of common occurrence, and of considerable size, varying 
from six to ten, or even fifteen inches in length, although 
occasionally, however, smaller, as from one to two inches 
long. It is usually of a whitish or brownish red colour, and 
occasionally blood-red. Its body is round, cylindrical, and 
pointed at both ends, but more decidedly at the anterior 
than at the posterior extremity. A delicate furrow runs along 
the body upon both sides. If the worm is examined under 
the microscope, it is perceived that the head is separated from 
the body by a kind of circular constriction, and presents 
three tubercles or peculiar valves, which can open and shut 
themselves, and have between them the proper opening of the 
mouth. In the interior of the body we may recognise the 
brownish intestinal canal which terminates in the anus, a 
little anterior to the extremity of the tail. This worm has 
the sexes distinct. The male is somewhat smaller, and has 
a more curved tail, from which, at intervals, the double 
penis is seen protruding. In the female, again, we may 
recognise the sexual organs, ovaries and oviduct, as white, 
partly thread-, partly riband-like organs which, when the 
worm breaks, readily fall out, and having become detached 
are frequently mistaken for individual worms. The ova 
measure the 25th of a line in length, and^have a thin 
smooth shell. 

The round worm is of very frequent occurrence in the 
small intestines of the human subject, especially in children. 
Its presence is not so injurious as is commonly supposed, for 
it is often found in great numbers without the slightest dis- 
turbance of the health. Yet it may certainly become trouble- 
some and even injurious, either by reason of its accumulating 
in great numbers, and exciting mechanical irritation in the 
intestinal canal, or even closing it up,* and thus producing 

* Haller observed an instance in which a girl aged ten years, died 
from the accumulation of ascarides in the fauces, mouth, trachea and 
bronchi. 



464 



PARASITES. 



gangrene, or by entering into the stomach. In certain cases 
it appears to be capable of even perforating the intestine, by 
thrusting asunder with its head the fibres of the intestinal 
coats : it thus passes into the cavity of the abdomen, where it 
gives rise to inflammation, suppuration and abscess. Some- 
times it even escapes externally through the abdominal walls. # 
These cases are, however, very rare. This subject will be 
continued in the special part.f That round worms are 
not generated spontaneously, but pass into the body from 
without, is scarcely questionable, although the manner in 
which this takes place cannot be, at present, demonstrated. 

See representations by Bremser, PI. i. fig. 13 to 17. Respecting its 
internal structure, vide Jules Cloquet, Anatomie des vers intestinaux 
ascaride lombricoide et echinorhynque geant, Paris, 1824. 

10. The ascaris alata, Beliingham, is a species once found in the 
human subject, namely in Ireland, by Beliingham ; the extremity of the 
head is furnished with membranous, semi-transparent alae, similar to 
those occurring in the ascaris of the cat, {ascaris mystax) but so far diffe- 
rent that, in a. mystax, this appendix is broader in front than behind, 
while in a. alata, on the contrary, it is broader behind than in front. 

Vide Dujardin, op. cit. p. 156. 

11. The thread worm, (oxyuris vermicularis, Brems. 
ascaris verm. Rud. is a thin white worm even smaller than 
the trichocephalus. These worms are of separate sex, and 
the male and female have a very dissimilar appearance. The 
male which is far the rarer of the two, is much smaller, 
varying in length from a line to a line and half, spirally 
coiled at the tail, and often completely assuming the form 
of a ring. The head is not much thinner than the tail, and 
under the microscope, shows a transparent tuberosity appa- 
rently forming lateral alae. The female is not annulated, but 
extends in a straight line, or at most slightly undulates. Its 
cephalic extremity corresponds to that of the male, and bears a 

"* See Oesterr. medic. Wochenschrift, 1843, p. 661. 
f See Siebold, op. cit. p. 667. 



THE LIVER-FLUKE. 



465 



similar vesicular tuberosity. From its head to its anterior third, 
the worm increases somewhat in thickness ; it then contracts 
in diameter, and terminates in the tapering awl-shaped tail, of 
which the extreme point is so fine, that it is totally invisible 
to the unaided eye. The eggs are not symmetrical, being 
more convex upon one side than upon the other : they 
measure the 36th of a line in length, and the 62nd in 
breadth. 

These worms occur very frequently, and in great numbers 
in the large intestines — particularly the rectum — of the human 
subject ; they are especially common in children ; and in the 
female sex, sometimes pass into the vagina. They are not 
particularly injurious, but frequently excite an intolerable 
itching of the anus, and in this way become very troublesome. 
In the vagina they occasion still more violent irritation. 
See figures in Bremser, PL i. fig. 6 to 12. 

SECOND ORDER. 

TREMATODA. 

1. The liver-fluke, (distoma hepaticum, Abilgaard; and 
dist. lanceolatum, Mehlis). These two species of distoma, 
resemble each other very closely. They are flat, ovo-lancet- 
shaped worms, of yellowish colour, and somewhat truncated 
at both ends. With the aid of a lens, we perceive upon 
them, two round suckers, of which the anterior, situated 
on the head, forms an actual mouth. Between it and the 
body lies a short, scarcely distinct round neck, which merges 
very gradually in the body. The second sucker is situated 
upon the abdomen ; it is roundish or oval, rather larger 
than the anterior, and instead of being perforated, forms 
only a blind sac. Between these two mouths, may be 
detected a third opening — the excretory duct of the sexual 
organs. The distomata are hermaphrodites. 

It is only very recently, and mainly through the labours of 
Mehlis, that we have acquired a knowledge of the distinction 
between the two species. 

vol. I. h H 



466 



PARASITES. 



The distoma hepaticum is larger, the young being four 
lines long, and one and a half line broad; while the full 
grown animal varies from eight to fourteen lines in length, 
and from one and three quarters to six lines in breadth ; its 
intestinal canal is ramified ; the eggs are brownish, the 1 7th 
of a line long, and half that breadth. 

Tne distoma lanceolatum is smaller ; from two to four lines 
in length, and scarcely one line broad ; its intestinal canal is 
bifurcated ; the eggs range from the 77th to the 48th of a 
line in length. 

These two species of distoma occur but rarely in the human 
subject. They have been found in the gall-bladder, in the 
biliary ducts, and once even in the vena portse and its hepa- 
tic ramifications, (Duval). # In animals, especially in sheep, 
these entozoa are of much more frequent occurrence. 
Although the nature and mode of their transference have 
not yet been clearly shown, it can scarcely be doubted that 
these animals enter the system from without, and do not 
originate in it. 

For representations and descriptions, see Bremser, PI. iv, fig. 1 1 and 
12; Mehlis, Observ. anat. de distom. hepat. et lanceolat. Gotting. 
1825 ; Guilt, Lehrbuch der patliol. Anat. der Haussaugeth. PI. vm, fig. 
29 to 05. Pvecpecting the metamorphoses which the distomata undergo, 
■which ere highly interesting in a zoological point of view, see Steen- 
strup.f iiber den Genera tionswechsel, Copenhagen, 1842, (or Busk's 
translation, published by the Ray Society) . 

2. The distoma oculi humani, Gescheidt, has been found 
only once (by Gescheidt) ; it was observed in a child aged 
five months, who had suffered from cataracta lenticularis 
cum partiali capsules suffusione, and had died of atrophia 
meseraka. Four lancet-shaped distomata ranging from a 
quarter to half a line in length, and with dichotomously rami- 
fying intestinal canals (dist. lanceolatum ?) were present 
between the lens and the anterior portion of the capsule, j 

* Gazette, Medic, de Paris, 1842, No. 49. 
t See Siebold, op. cit. p. 669. 

t Amnion's Zeitschr. f. Ophthalmologic, vol. in. p. 434. 



TAPE WORM. 



467 



To the trematoda also belong the eight portions of mo- 
nostoma (.nonosloma lentig\ , discovered by Nordmann in the 
opaque lens of a woman. 4 

3. The polysioma pinguicola, Rud. and Bremser ; hexathyridium pin- 
guic. Treutl., lias been found only once, and possesses no great value 
in relation to pathology. It was discovered in the human ovary by 
lYeu'der. The animal lay free in a cavity formed by fat, was about an 
inch in length, and from two to three lines in thickness. Its form was 
a Jongish oval, above slightlv arched, beneath somewhat hollowed out, 
pointed behind ; the anterior portion was obtuse, and behind the head 
somewhat constricted; it presented upon its underside, six minute open- 
ings (suckers) arranged in a semilunar form. An additional larger sucker 
was observed on the abdomen at its point of junction with the tail. 

The nature and mode of origin of this animal is involved in perfect 
darkness. See representations in Bremser, PI. iv, fig. 15 to 17. 

TreutJer has observed another worm of this kind (hexathyridium vena- 
rum, polysfomh ven.) ; it was found in a young man s tibial vein (which 
had been lacerated whilst bathing), and he conceives it bad dwelt in the 
blood-vessels. This explanation, however, is unquestionably incorrect, 
and the worm (pe?haps a planaria) most likely, during the bath, entered 
the vein from without. Compare Bremser, p. 265. 

THIRD ORDER. 

TAPE WORM, CESTOIDEA. 

1. The common tape worm, {taenia solium, t. vulgaris, t. 
cucurbitina) , is a riband shaped, very long worm of milk white 
or yellowish colour. Its length may exceed twenty feet (and may 
reach even twenty ells) ; its breadth at the extremity of the head 
is small, scarcely a quarter or third of a line ; but in passing 
backwards, gradually increases to three, four, or even six lines. 
The thickness ranges from a quarter of a line to a line. The 
worm is jointed ; the individual joints are flat, more or less 
quadrangular, frequently of the form of a gourd seed with a 
blunted point, and commonly longer than they are broad. 
They are characterized by the circumstance, that all or at 
least the greatest number, present upon the margin a mam- 



* Mikrographische Beitr. Part 2, p. 9. 

H H 2 



468 



PARASITES. 



miliary projection with a distinct opening in the centre. 
These projections form the orifices of the sexual organs, and 
are situated without fixed order, sometimes on the left, 
sometimes on the right margin of the joint ; occasionally, 
however, their position on the separate joints varies according 
to rule. The head of the worm occupies the anterior thin 
extremity, and is very minute, commonly hemispherical, 
broader than it is long, and often appears as if curtailed in 
front. Its essential character only becomes evident upon the 
application of magnifying glasses. It then exhibits four lateral 
mam miliary suckers, and between these, in the middle of the 
head, an arched eminence upon which is always remarked a 
circle, in whose centre a minute, scarcely perceptible opening 
exists. Upon this circle are sometimes seated small hooks in 
double rows. This double circle of hooks may, however, be 
absent ; indeed, it appears, that with advancing age the worm 
always loses it. The head merges into a flat, unarticulated 
neck, which varies in length and is followed by the articulated 
body. The first joints are very short, the following almost 
square, while the more posterior are longer than they are broad ; 
the joints are narrower in front, thicker and broader behind, so 
that the posterior extremity of each, projects over the commence- 
ment of the following ; the last joints are sometimes twice or 
three times as long as they are broad. The growth of the 
worm takes place in this manner : from the neck, new joints 
are continually evolved, which push those behind still further 
back, and develop themselves in proportion as they regress. 
The hindmost joints are, therefore, the oldest, and at the 
same time, the most perfect. Yet it appears that new joints 
are developed not only from the neck, but may be in- 
troduced between the perfectly developed articulations, even 
at the posterior end of the animal. The increase of the worm 
is, however, not unlimited ; when the last joints have attained 
to their perfect development, and are filled with mature ova 
they detach themselves, and, either uninjured, or in a state 
of decomposition, are evacuated by stool. Since the joints 



TAPE WORM- 



469 



which are thus thrown off, are continually being replaced by 
new ones, it is absolutely necessary, in order that the annoy- 
ance caused by the worm shall cease, that the whole animal, 
including even the extremity of its head, should be eva- 
cuated. 

The taenia solium inhabits the small intestines of the 
human subject, but only in certain districts ; it occurs ordi- 
narily — indeed, almost exclusively — in Germany, England, 
Holland, Egypt, and the Levant. Commonly there is found 
but one tape-worm in the intestinal canal ; sometimes, how- 
ever, several are simultaneously present. It is pretty well 
ascertained that the innumerable ova which a single individual 
of this class may produce in a short time, cannot develop 
themselves in the intestinal canal of the patient, but must 
quit him in order to experience unknown changes out of his 
body. The manner in w T hich this worm finds its way into the 
intestinal canal, cannot yet be pointed out ; but numerous 
reasons entitle us resolutely to reject the opinion, that it may 
have spontaneously originated. We must, therefore, assume 
a transference of it from without. 

It cannot be denied that the tape worm, by its presence in 
the intestinal canal, may cause derangement of the organism ; 
nevertheless its pathological importance is commonly over- 
estimated. It often remains in the body for a long time 
without its presence being revealed by the slightest symptom; 
sometimes, particularly when of great size, its movements 
become annoying and unpleasant. 

See representations in Bremser, PI. in. The disorders occasioned by- 
it will engage our further attention in the special part. See Wawruch, 
Monographic der Bandwurmkrankheit, Wien, 1844, in which, how- 
ever, the description of the worm, and of its physiological relations, 
(p. 34, et seq.) do not perfectly correspond with the present state of our 
knowledge. — Th. v. Siebold, on the escape of a tape worm through the 
umbilicus, Oesterr. medic. Wochenschr. 1843, p. 660. 

2. The broad tape worm, (bothriocephalus latus, taenia 
lata, in many respects, so closely resembles the preced- 
ing, that we may shorten its description, and content 



470 



PARASITES. 



ourselves with noticing their distinguishing characters. Like 
the taenia vulgaris, it is a flat, usually distinctly articulated 
worm, which can attain to a length of from one foot to 
twenty, or even forty or more feet, and likewise at the 
cephalic extremity, is not more than a quarter or half a line 
broad ; posteriorly it acquires a breadth of four, six, or 
twelve lines. Its colour is whitish or light gray; its thickness 
from the sixth to half of a line. The individual joints of the 
worm are quadrangular, in general, broader than long; their 
length, however, increases in proportion as they become 
distant from the cephalic extremity. The well developed 
joints want the mammillary projection on the margin, but in 
the place of it have, each in its centre, a distinct depression — 
the genital opening — surrounded by an elevated ring. On the 
larger joints may sometimes be remarked, behind this opening, 
a second smaller one. The head of the worm, as in the case 
of taenia vulg. is very minute ; but, the application of the 
microscope reveals well-marked differences. Jfc has no suckers, 
but instead of them, two (not always evident) depressions, or 
furrows running longitudinally. 

The neck is very short, often entirely absent. The dis- 
crimination of this worm from the taenia vulg. is easy, and is 
to be accomplished — partly through the well-developed joints, 
which are thiown oif not singly, as in the taenia vulg., but 
in connected rows, and which are characterized with certainty 
as of the family hothriocephalus, by the presence of the above 
mentioned cavity in the centre, and not on the border of the 
joint — and partly through the examination of the cephalic 
extremity, when that is possible. 

The bothriocephalus likewise inhabits the small intestines 
of man, but only in certain countries — in Switzerland, in 
Middle and Southern France, Russia, Poland and Eastern 
Prussia, where the Vistula forms the boundary between its 
territory and that of the taenia vulgaris.* When it occurs 



* See Siebold, op. cit. p. 652. 



CYSTICERCUS CELLULOSA. 



471 



in other districts, where the taenia prevails, we may be 
assured that the patient is a native of one of the above-named 
countries, or at least has caught it there. 

With respect to its origin and pathological importance, 
there is nothing to add beyond what has been stated of the 
taenia vulgaris. 

See representations in Bremser, PI. n. See also the very interesting 
paper by D. F. Eschricht, anat. physiol. Untersuchungen iiber die Both- 
riocephalen, (Nova acta acad. Caes. Leop. vol. xix. suppl. 2), which 
also contains some general remarks well worthy of consideration, against 
the view of the spontaneous origin of intestinal worms. 

FOURTH ORDER. 

CYSTICA. 

1 . The cysticercus cellulosa, (hydatis finna, Blumenb.) 
consists of an oval vesicle varying in length from three 
to eight lines : it possesses an extensible neck, terminating in 
a head, which together with the neck can be protruded and 
retracted, and in the latter case may be entirely over- 
looked by a superficial observer. The head when protruded 
is quadrangular, and has, at each of its four corners, a sucker ; 
on the fore part of the head, situated at the base of a conical 
proboscis, is a double circle of hooks, amounting in number 
to about thirty-two. Extended to its full length the animal 
may measure from half an inch to an inch ; its breadth at the 
cephalic extremity amounts to about one line ; at the vesicular 
portion, to about six lines. 

As in the case of the trichina, this worm is found in the 
muscles of the human subject — most frequently in the psoas, 
the glulcei, iliacus internus, the extensors of the thigh, and 
in the heart ; also, however, in the cellular tissue, in the 
brain and pia mater, and sometimes, but very rarely in 
the eye. We sometimes observe a solitary worm ; sometimes 
they occur in great numbers. It is almost invariably, at least 
when occurring in parenchymatous parts, surrounded by an 
enclosed capsule, which, however, is not essential to it, but 



472 



PARASITES. 



is a product of the part in which it dwells. It owes its origin 
to fibrinous effusion, of which the fibrin coagulates, and is 
organized according to the mode formerly explained (p. 242). 
It appears that this capsule, as in the case of the trichina, may 
sometimes become filled with calcareous salts, and after the 
death of the worm become converted into a concretion. 

The pathological importance of this worm is entirely de- 
pendant on the tissue or organ it attacks. Whilst in many 
instances, as for example, in the brain, it may oocasion 
serious accidents, or even death, the presence of a small 
number in the muscles or cellular tissue, often excites no 
symptoms of any sort. 

It is figured in Bremser, PL iv, fig. 18 to 26, who has collected a 
number of the early cases in which it was observed in man, (p. 241). See 
also Tschudi, die Blasenwiirmer, Freiburg, 1837. An excellent micro- 
scopic representation is given by Gulliver, in his Observations on the 
structure of the entozoa, belonging to the genus Cysticerus. Medico- 
chirurg. transactions, 1841, p. 1 et seq. The following cases have 
been recently described : Fournier mentions an instance in which seven 
or eight cysticerci occurred in a boil upon a child aged six years.* It 
has been observed in the eye by Sommering, Mackenzie,! HeringJ and 
Logan. || It is extremely probable that the cysticerci are abortive and 
dropsical t(Eni<£,§ which have entered the body from without; but 
chancing to establish themselves in a spot unfavourable to their develop- 
ment, gradually degenerate without leaving issue; ova are never 
found in them ; the roundish bodies with the property of refracting light, 
which are perceived in their structures by the microscope are not ova, 
but calcareous deposits, which dissolve with effervescence in acids. In 
the brain the cysticercus may produce dangerous symptoms. I examined 
a dog, which for some time had been completely blind, and in the 



* Journ. des connaiss. med. chirurg. Juin, 1841. 

t Gescheidt, in Amnion's Zeitschr. f. Ophthalm. vol. in. p. 416. 

t Dublin Journal of Medical Science, Jan. 1841, p. 500. Other 
cases are recorded in Mediz. Vereinszeit. 1838; Froriep, N. Notiz. 
1838, No. 170; Annales d'oculistique, Mars, 1842; Oesterr. mediz. 
Wochenschr. 1843, No. 11 ; and Rayer, Archives de pathol. comparee, 
t. i. p. 125. 

II Todd's Cyclopaedia, art. Entozoa, p. 119. 

§ Dujardin, Histoire des Helminthes, p. 633. 



ECHINOCOCCUS HOM1NIS. 



473 



highest degree apathetic. Upon dissection I found the whole substance 
of the brain interspersed with cysticerci. 

The existence of the cysticercus visceralis described by some as a 
human entozoon is extremely problematical. See Bremser, p. 244. 

2. The echinococcus hominis, consists in the first place of an 
external vesicle, which, as in the case of the cysticercus ,is formed 
by, and is firmly united to the part of the body in which the 
entozoon is situated. It owes its origin to coagulated fibrin, 
which, however, becomes gradually organised, and even inter- 
sected with vessels. It generally consists of fibrous tissue, which 
on its inner surface is coated with a more or less perfect epi- 
thelium. This membrane is sometimes thick, and has the 
cartilaginous condition not unfrequently shown by amorphous 
fibrous tissue generally (see p. 218). Within this membrane 
which does not pertain to the worm, there lies, perfectly 
loose and free from all organic connection with it, a second 
membrane which forms a completely shut sac, filled with 
fluid. This second membrane presents a jelly-like transpa- 
rency, but is sometimes milk-white ; under the microscope it 
appears perfectly structureless, and may commonly be split 
into a very great (but indefinite) number of laminse; this 
appearance is very obvious on placing a section of it under the 
microscope, when it is seen to resemble the leaves of a book. 
With chemical reagents this membrane behaves like coagu- 
lated fibrin. In the interior of this cyst, there exists a fluid 
which either encloses smaller vesicles of varying size, or on 
standing for some time, deposits a finely granular matter, 
which almost resembles pus, or more closely approximates in 
appearance to fine white sand. Under the microscope this 
granular matter resolves itself into a number of animalcules 
which present some resemblance to the diminished head 
of a cysticercus. Like this, they usually bear on the one ex- 
tremity a series of hooks, behind which there are several (usually 
four) suckers ; the body usually contracts to an obtuse conical 
tail, which is sometimes separated from the fore part by a 
kind of constriction. This is the ordinary form of the ani- 



474 



PARASITES. 



malcule ; other forms, however, sometimes occur. They may 
present a double cordiform shape (like two contiguous hearts, 
as they are depicted on playing cards, with their apices cut 
off), or they may appear circular when the animalcule is viewed 
from above — in which case the ring of hooks appears in the 
centre. It seems to be able to retract the cephalic ex- 
tremity with the circle of hooks ; for the latter sometimes 
occupies the interior of the body. Sometimes the posterior 
extremity is drawn out to a pedicle, and presents a distinct 
opening. Sometimes the circle of hooks is absent, being 
apparently thrown off. Isolated hooks are then seen in 
the fluid. With higher powers, clear, vitreous globules of 
varying size, which entirely correspond with those described 
in the cysticercus, and consist of calcareous salts, are seen 
in their interior. The animalcules vary from the 8th to 
the 20th of a line in length, and from the 10th to the 
30th of a line in breadth. Sometimes they are free in the 
interior of the cyst, and in this case form, with the fluid con- 
tained in it, a kind of emulsion ; sometimes they seem adhe- 
rent to the internal wall, which then presents the appearance 
as if it had been sprinkled over with fine white sand. Some- 
times these animalcules are enclosed in small vesicles varying 
from the size of a pea to that of a nut, which lie free in the 
interior of the cyst, or are attached to its walls, or there is 
found within the common parenchymatous cyst, instead of 
one simple vesicle, a large number of various sizes. In certain 
cases the animalcules have died, and disappeared without 
leaving even a trace ; on a microscopical examination a large 
quantity of isolated hooks are then perceived in the fluid, or 
at least in its sediment, besides indefinite detritus and 
crystals of cholesterin. Wherever these are absent, we 
have no right whatever to regard the structure as the 
remains of an echinococcus. Sometimes after the death of 
the animalcule, the cyst becomes metamorphosed into a con- 
cretion ; protein-compounds and calcareous salts are deposited 
within it, and it then closely resembles a cretaceous tubercle. 



ECHINOCOCCUS HOMINIS. 



475 



The echinococci are found by far the most frequently in the 
parenchyma of the liver, but occasionally also in that of other 
organs, as the spleen, kidneys, brain, and lungs. Their 
pathological importance is principally a mechanical one ; since, 
like other tumours, they exercise an injurious pressure on the 
tissues which invest them, or give rise to suppuration, 
abscesses, or fistula, in the neighbouring parts. The 
means by which they gain access to the body is still altoge- 
ther problematical ; yet I entertain no doubt, that they do not 
arise spontaneously, but that they owe their origin to an 
animal introduced from without, whose other states and 
grades of development are either still unknown, or are so 
widely different from the echino coccus, that their connection 
with it has hitherto escaped observation. 

Representations and literature. Good representations of the echinococ- 
cus are still wanting. I cannot but question whether those of Bremser 
in PI. iv, fig. 27 to 32, represent this animal. But the representations 
of the echinococciis veterinorum of the dromedary, given by the same 
author in his Icones Helminthum, Vienna, 1824, PI. xviii. fig. 3 to 13, 
afford a tolerably correct idea of the human parasite, except that in the 
echinococci depicted in fig. 6, the circle of hooks is not distinct, and 
the isolated hooks there represented do not accord with reality. 
Tschudi, (die Elasenwiirme, Freiburg, 1837), has copied Bremser's 
figures, and added a few very defective ones. Curling's Plate in the 
Medico- chiruvg. trans. 1840, p. 385, PI. n, fig. 3, is nothing remark- 
able. Two years ago I had an opportunity of examining a highly inte- 
resting case of eckinococcus in the liver, and am indebted to the kind- 
ness of my friend Dr. Kohlrausch. of Hanover, for the details and repre- 
sentation of another case occurring in the same organ. A case, like- 
wise in the liver, is also described by Lebert.* J. Miiller has observed 
an instance in which echinococci, no doubt proceeding from the kid- 
neys, were discharged with the urine.f Gescheidt has found this animal 
in the eye, between the choroid and retina. % See also Gluge, Abhand- 
lungen zu Physiol, und Path. Jena, 1841, p. 196 ; Roozeboom, Dissert, 
de hydatidibus, Schoonhovise, 1836, in which there is a tolerably 
copious bibliography, from which I will here only quote the very labo- 

* Miiller's Archiv. 1843, p. 217. 

t Miiller's Archiv. 1836, Jahresber. p. 107. 

t v. Ammon's Zeitsch. fiir Opthalmologie, vol. in. p. 437. 



476 



PARASITES. 



rious dissertation by Liidersen, de hydatidibus, Gottingae, 1808, 4. 
These latter treatises refer partly to this, partly to the following sec- 
tion.* After the interesting researches of Siebold (Burdach's Physio- 
logic, 2, 183), we must suppose their growth to take place in the 
following manner ; upon the interior of the primitive cyst minute points 
spring forth ; these gradually form echinococcus-animalcules which after- 
wards detach themselves from the parent cyst. Instead, however, of 
isolated echinococci, secondary cysts may be developed from the parent 
cyst, which then give origin to isolated echinococci ; from these secondary 
cysts, tertiary cysts may perhaps be developed, and so on. We might, 
accordingly, regard the echinococcus-vesicles as nurses (ammenthiere), 
probably performing their office in the same way which Steenstrup has 
shown to occur in the case of the distomata. Our knowledge on this 
point is, moreover, still deficient, and further researches are very desi- 
rable. I conceive it to be possible that the vesicle lying within the 
parenchymatous cyst, is in many instances, the product not of the 
animal, but of the organism ; see the description of Plate v. fig. 5. 

3. Acephalocysts — hydatids. Whilst the true echinococci 
which have been just described, are undoubtedly animals, 
there are other structures closely resembling them, whose 
animal nature is, at least, very questionable. These are 
the acephalocysts of Laennec. They, like the echinococci, 
consist of an external cyst, arising from the parenchyma, 
usually exhibiting evidence of organization, and doubtless a 
product of the organism. Within this is a second cyst per- 
fectly similar to that of the echinococci, containing in its 
interior a clear fluid which, again, includes smaller vesicles. 
Sometimes these smaller vesicles are attached to the inner 
wall of the parent cyst. In certain cases the parenchymatous 
cyst contains, not merely one simple vesicle, but several 
of various sizes. These acephalocysts are thus essentially 
distinguished from the echinococci, by their containing neither 
echinococcus-animalcules, nor the rejected hooks which 
might lead us to infer the presence of dead and disintegrated 
echinococcus-animalcules. The acephalocysts may, like the 
echinococci, assume a tubercular appearance, or be converted 
into concretions ; they likewise occupy the same localities, 

* See also Siebold, op. cit. 678. 



HYDATIDS. 



477 



exist under the same relations and in pathological importance, 
resemble them in every respect. 

With regard to their origin, there are two opposite views. 
According to the one, maintained by Laennec, Owen, Lallemand, 
and others, they are animals either specifically distinct from 
echinococci or identical with them — nurses (ammenthiere) 
which never attain to the development of echinococcus-animal- 
cules. According to the other, they are no animals at all, 
but morbid products of the human organism, which are per- 
fectly analogous to the hydatids, formerly noticed, and arising 
in the same manner (see p. 242). Many structures considered 
as acephalo cysts — as for instance, the vesicular hydatids of the 
peritoneum and other serous membranes, the cystic moles 
of the uterus, and the greater number of the encysted drop- 
sies—are to be ranged, no doubt, in the latter category ; and 
if the first mode of origin of the acephalocysts — their animal 
principle — should become positively established, (which 
future researches must decide, but which seems to me very 
improbable,) it will certainly prove that only a very 
small number of the so named acephalocysts, are of an ani- 
mal nature. 

The literature respecting acephalocysts is exceedingly abundant. I 
shall here notice only the most important Memoirs : Diction, de med. 
art. Acephalocysts; H. Cloquet, Diet, des sciences med. t. xxn. p. 156 ; 
Phobus, Encycl. Worterbuch d. mediz. Wissensch. Berlin, 1834, v. x. 
p. 62 ; Tschudi, die Blasenwiirmer ; Kuhn, Recherches sur les acepha- 
locystes et sur la maniere dont ces productions parasites peuvent don- 
ner lieu a des tubercles, Strasbourg, 1832, avec planches ; also in 
Annales des Sciences natur. t. xxix. 1829, p. 275 ; Jaeger in Meckel's 
Archiv. 1820, vol. vi. p. 495 et seq. ; Michea, Archives generates de 
med. Mars. 1841, p. 341 ; Aran in ditto, Sept. 1841, p. 76. In a che- 
mical point of view, the contents of most acephalocysts correspond with 
the fluid of serous dropsy, whilst the cyst-membrane possesses all the 
characters of coagulated fibrin. The transition of hydatids into depo- 
sits resembling tubercle and into concretions, long since attracted so 
much attention, that some inconsiderately have regarded all tubercles 
and concretions as proceeding from hydatids. See Ruysch, Dilucid. 
valv. vas. lymph. Obs. 25, p. 25. Lallemand avers that he has per- 



478 



PARASITES. 



ceived voluntary motion in the acephalocysts of the human subject.* 
Yet in such observat'oas deception is so easily possible, that I do not 
attach any great weight to them. Klenke has communicated nume- 
rous observations respecting hydatids, and states that he has very fre- 
quently propagate u. them to animals by inoculation.! But most of his 
statements are impressed, in so high a degree, with the character of 
improbability and exaggeration, that I cannot resolve in this place to 
avail myself of his communications, which if true would possess a high 
interests 

PSEUDOPARASITES. 

The animals which have been described in the preceding 
pages are the only parasites which hitherto have been certainly 
recognised as inhabitants of man, although we may anticipate 
that more extended researches in foreign countries and diffe- 
rent climates will disclose many others. Moreover, many 
incidental parasites have been observed which in part have 
been already mentioned, and in part will be considered, with 
their effects and with the pathological alterations to which they 
give rise, in the special department of the wo*'k. 

If, however, we glance at the annals of science, we find 
exhibited a great number of cases, in which other para- 
sites than those described are stated to have been observed, 
and new instances of the kind daily appear, in which physi- 
cians affirm that they have observed parasites on man, but 
where, in fact, no parasite was present. These cases may be 
reduced to two classes : 

1 . Cases in which various animals are stated to have been 
evacuated from the human sabject, by stool, urine, or vomit- 
ing. Here there can be no doubt respecting the animal nature 
of the object in question, but physicians err in supposing that 
these animals were parasites. They did not exist in the 
body, and only appeared incidentally in the excretions ; 
thus worms, larvae, acari, and even beetles, are sometimes 

* Annales des sciences natur. t. xv. p. 292. 

f Ueber die Contagiosity der Eingeweidewiirmer, &c, Jena, 1844. 
t See also Siebold's critique on these views, op. cit. p. 651. 



PSEUDOPARASITES. 



479 



found in the urine ; these, however, were not dis- 
charged with the urine, but previously existed in the utensil ; 
the like occurs in the faecal evacuations, in vomited matters 
and in sputa. Ia some of these cases the deception is inten- 
tional, and proceeds from the patients who assert that they 
have discharged these animals, when they have previously cast 
them into the utensil; sometimes this is done with a view to 
excite interest, and often from totally inexplicable psycholo- 
gical motives, the patients having even previously swallowed 
them, in order more effectually to deceive the physician. 

2. The substances supposed to be parasites may indeed 
have been actually discharged, but are, however, no ani- 
mals, but other foreign bodies of the most varying description, 
as seeds and other vegetable matter, morbid products (fibri- 
nous coagula, &c.) In order to escape such errors which 
even in modern times, occur sufficiently often, whenever the 
physician entertains a doubt respecting the nature of an eva- 
cuated body, he should always consult an experienced natu- 
ralist. 

It is not our intention to enumerate all the pseudoparasites 
hitherto met with, but merely, once for all, to caution the 
physician to be on his guard in such matters, and neither to 
fall spontaneously into error, nor allow himself to be deceived 
by others. 

A series of pseudoparasites, which might be easily augmented by some 
more recent examples, has been described by Bremser, and figured in 
the vignette on the title page of his work.* 

* Siebold's remarks on this subject are well deserving of the atten- 
tive perusal of every practical physician, op. cit. p. 683. 



480 



MALFORMATIONS, 



CHAPTER IX. 

CONGENITAL MODIFICATIONS OF THE HUMAN BODY— 
(MALFORMATIONS) . 

A special consideration must be devoted to those morbid 
changes which originate not, as is for the most part the case 
with those hitherto described, after birth, but during foetal 
life, and which, consequently, the infant brings with it into 
the world. 

These congenital changes may be reduced to two divisions, 
which, however, are not strictly separable from one another. 
Those belonging to the first division differ in no respect from 
the morbid changes already considered ; indeed, it has been 
already frequently mentioned, that certain tumours are occa- 
sionally formed in the foetus in exactly the same manner as 
they arise after birth. This, for instance, was stated in 
relation to congenital telengiectasies, lipomata, encysted 
tumours, &c. These congenital changes, accordingly, present 
little or nothing peculiar; we shall, therefore, only briefly 
notice them at the conclusion of this chapter. 

In addition to these there are, however, other morbid 
changes, which occur only in the foetus, and of which it 
has never yet been observed, that they have originated in 
the same way after birth. These latter are termed malfor- 
mations — vitia primte conformationis. 

The peculiarity of these malformations, and their essential 



MALFORMATIONS. 



481 



difference from ordinary morbid changes, are explained by 
the following considerations : — immediately after birth almost 
all the organs exist in a condition which, with slight modifi- 
cations of form, they retain throughout life. All organs, 
indeed, grow until they are perfectly developed ; but this 
growth is, for the most part, merely a simple augmentation 
of bulk. A few organs only, as the sexual apparatus and 
the thymus gland, undergo at a later period comparatively 
important modifications, either developing themselves more 
highly, or, on the other hand, disappearing. Indeed, in adults 
the changes of the body are, in the normal state, almost solely 
confined to renewal of material (metamorphosis of tissues), 
whilst the form of the organs, with very trivial modifica- 
tions, remains unaltered. The case is different with the 
embryo and foetus. Here, as the laws of development teach 
us, the various parts and organs of the body are gradually 
developed from the simple stroma of the ovum. During 
foetal life we have, therefore, not merely nutrition, as after- 
wards, but also development ; and whilst, after birth, patholo- 
gical influences only affect existing structures, or, at most, give 
rise to the introduction of heterogeneous matters, previous to 
birth morbid influences extend their operation even to the 
development, so that pathological structures are generated, 
which differ considerably from those occurring after birth. 

This appears to me to be the best mode of expressing the essen- 
tial nature of malformations, and their distinction from those patho- 
logical changes, which occur not merely in individuals after birth, but 
occasionally in the foetus. The relation of malformations to pathological 
anatomy, spontaneously results from it. If the latter, in the sense in 
which we here receive it, is allowed to include all cognizable pathological 
changes occurring in the human subject, then malformations must be 
included in it. Whilst, however, the study of ordinary pathological 
changes pre-supposes, in addition to an acquaintance with pathology and 
physiology, merely a knowledge of normal anatomy, the study of malfor- 
mations, if it is to lead to the comprehension of their origin, demands a 
profound knowledge of the history of development ; indeed, these two 
latter subjects are in immediate relation. And hence I do not object to 
VOL. I. I I 



482 



MALFORMATIONS. 



the view of those who, like Isidore Geoffroy St. Hilaire,* desire to form 
of the doctrine of malformations a special science, under the name 
of Teratology. Malformations have much less practical interest than 
other pathological changes, since the greater number of them can neither 
be prevented, nor, having once arisen, can be removed by remedial mea- 
sures. For this reason, and because the number of malformations is 
exceedingly great, I cannot here enter into the details of this subject 
with the fulness with which it has been treated in various other 
works on pathological anatomy. I shall content myself with a 
superficial exhibition of the various malformations ; and, for a complete 
study of the individual forms, must refer partly to the special depart- 
ment of this work, and partly to the works and memoirs quoted in the 
separate cases, and to the special treatises on malformations ; of which 
the following deserve particular recommendation : 

A. v. Haller, demonstris, in oper. minor, t. in. Lausanne, 1768. where 
the best scientific collection of the older literature is to be found ; J. F. 
Meckel, Handbuch der pathologischen Anatomie, vol. i. 1812, vol. n. 
1816; Isidore Greoffroy St. Hilaire, Histoire des anomalies de l'organi- 
sation, t. I. Paris, 1832, t. n. and in. 1836 ; W. Vrolik, Handboek der 
zicktekundige Ontleedkunde, vols i. and n. 1840 — 1842, also under the 
title : de menschelijke Vrucht beschouwd in hare regelmatige en onre- 
gelmatige Ontwikkeling ;f Otto, Monstrorum sexcentorum descriptio 
anatomica. Vratislav. 1841, fol. — a splendid work, with thirty plates; 
F. A. Ammon, die angebornen chirurgischen Krankheiten des Menschen. 
Berlin, 1840 — 1841 ; Gurlt, pathologische Anatomie der Haussauge- 
thiere, vol. li., treating of the malformations occurring in domestic 
animals— a subject which, in a comprehensive study of this department, 
must not be disregarded. 

An excellent sketch of the general relations of malformations, with 
especial regard to the history of development, may be found in the 
Article " Entwicklungsgeschichte, mit besonderer Beriicksichtigung der 
Missbildungen," by BischofF, in Wagner's Handworterbuch der Physiol, 
vol. I. 

The fabulous malformations of the ancients have been collected by 
Berger de Xivrey, traditions teratologiques. Paris, 1836. 

* Histoire des anomalies de l'organisation, vol. in. p. 447, &c. 

f As, in consequence of the language in which it is written, this 
interesting work is accessible to comparatively few readers, I may refer 
to a very copious review of it by v. d. Busch in the Hannov. Annalen. 
fur die gesammte Heilk. 1843, No. vi., and 1844, Nos. i. n. 
and in. 



THEIR CAUSES. 



483 



The causes of most malformations are, undoubtedly, patho- 
logical influences, perfectly analogous to those which occasion 
morbid changes in the body after birth. Probably, like the 
latter, these also are very manifold ; and it appears to me a 
limited mode of viewing the question to endeavour, as is 
not unfrequently done in pathology in relation to different 
diseases, to trace all malformations to one, or to only a few 
causes. Experience, as well as analogy, leads to the inference 
that the causes not merely of different, but even of the same 
kinds of malformation, may be very dissimilar. How- 
ever, at present we unfortunately know very little respect- 
ing these causes, The following propositions represent the 
actual state of our knowledge on this subject : The human 
embryo is formed by the co-operation of the male and female 
generative matter — the semen and the ovum. By means of 
a fruitful coition, an impulse to further development is com- 
municated to the ovum. A normal development, therefore, 
primarily assumes normal generative matter in both sexes. In 
order, however, that a normal foetus may be produced, it is 
further essential that the maternal organism should supply all 
the conditions necessary to the development of the embryo, 
and that the development should in no way be disturbed by 
external influences, or by diseases of the foetus. 

Accordingly, we may regard as causes of malformations : 

1 . Abnormalities of the generative matter of one or both 
parents. Numerous phenomena in man and animals lead to the 
conclusion that the condition of the father exercises an influ- 
ence upon the condition of the offspring, which in many cases 
at least, can be effected only through the intervention of the 
generative matter, and that this influence may be extended 
even to the production of malformations. Thus we frequently 
see that children exhibit the peculiarities of the parents. Mal- 
formations are transmitted from the parents to the children ; 
and if, in the case of the mother, the two causes, which will 
be presently noticed, possibly co-operate, this, at least, does 



i i 2 



484 



MALFORMATIONS. 



not hold good in relation to the father. In this class we 
may also include the eases in which several children, whose 
parents present no peculiarity, suffer from the same mal- 
formations. 

Cases of this kind are by no means unfrequent, and may be daily 
observed. A large number has been collected by Meckel.* See, also 
Gurlt.f and Henle.J 

The great majority of these cases admit of no other expla- 
nation than that the malformation had its origin in an original 
abnormality of the generative matter. But in what this 
abnormality consists, and how it operates, are points upon 
which really nothing is known, although, in solitary instances, 
an abnormal condition of the semen, (of the seminal animal- 
cules,) or of the ovum (of the yelk) has been observed. § 

2. As a second series of causes which, after impregnation 
has been effected, possibly take a part in the production of 
malformations, may be considered, abnormalities of the ma- 
ternal organism : — pathological alterations in the fallopian 
tubes and the uterus, bodily diseases and psychical affections 
of the mother. Of all these causes it may, with probability, 
be conjectured that they exercise a disturbing influence upon 
development, but we are still very far from knowing in what 
this consists, and what share it exerts in the production of 
malformations. It is probable that these causes operate by 
arresting and interrupting development, and consequently 
giving rise to various malformations by arrest of struc- 
ture. We must here also notice the opinion that some mal- 
formations owe their origin to an influence on the imagination 
of the mother during pregnancy — a psychical affection, in 
consequence of which the foetus is stated to bear upon it 

* Op. cit. vol. i. p. 15—59. 
t Op cit. vol. ii. p. 5—172. 

% Zeitschr. f. rat. Mediz. v. Henle u. Pfeufer, vol. n. p. 7. 
§ See Bischoff. Op. cit. p. 884. 



THEIR CAUSES. 



485 



certain characters which resemble the object that acted on the 
maternal imagination. This theory is in the highest degree 
improbable, if it cannot be positively denounced as false. * 

3. Diseases and abnormal states of the placenta, of the 
membranes of the ovum, and of the umbilical cord, may be 
regarded as causes of malformations. These generally induce 
an arrest of formation, by disturbing the process of develop- 
ment, and we may point out individual deviations from a 
normal state, which can with much probability be regarded 
as causes of certain malformations. Thus shortness of the 
funis and deficient union of the vessels forming it into one 
common cord, favour the origin of abdominal fissures, and of 
congenital umbilical hernia; or if the funis be of disproportionate 
length, it may coil around the extremities, constrict them, and 
thus render their nutrition defective, or even cause their ampu- 
tation. Union of the foetus with the amnion may likewise 
give rise to malformations, through pressure or tension.f 

4. Amongst the most frequent causes of malformations, 
we must undoubtedly consider various morbid influences 
acting directly on the foetus, as mechanical injuries, and dis- 
eases affecting it. From the experiments of Geoffroy St. 
Hilaire and Valentin,! it appears that by various mechanical 
influences to which hen's eggs are submitted during incuba- 
tion, the development of the embryo is partly interrupted 
and partly modified in such a manner as to give rise to mal- 
formations. Many observations tend to the conclusion that 
by means of mechanical influences (ill treatment by kicks, 
blows, or falls,) affecting the womb in the early months of 
pregnancy, certain malformations by arrest may be produced, 
as hemicephalia. The experience that malformations, such 
as acephalia, which depend upon a very decided arrest of 

* See Bischoff, Op. cit. p. 885 ; and G. Rubner, iiber das sogenannte 
Versehen der Schwangern. Dissert. Erlangen, 1839. 

f Several cases of this nature have been collected by Henle, in his 
Zeitschrift f. ration. Mediz. vol. n. p. 11, &c. 

X Repertorium, vol. n. p. 168. 



486 



MALFORMATIONS. 



development, usually occur in twin or triplet pregnancies, is 
favourable to the view that pressure and confined space are to 
be regarded as causes of certain monstrosities ; for the objec- 
tion which has been made, that twins and triplets are also 
born perfectly normal, only shows that, notwithstanding the 
limited space, a normal development is possible ; but not that, 
under specially unfavourable relations, the presence of a second 
embryo cannot exercise an interrupting influence upon the 
development of the other. Of diseases of the foetus 
which are capable of causing malformations, we at present 
recognize dropsical accumulations of water in its various 
cavities — no doubt one of the most frequent causes of hemice- 
phalia, spina bifida, abdominal fissures, and hernia umbilicalis 
congenita ; inflammation of certain organs at an early period, 
which through the agency of fibrinous dropsy may give rise 
to union, or even destruction and atrophy of certain parts ; and 
nervous diseases, inasmuch as they cause spasmodic contrac- 
tions of individual muscles or muscular groups, and in this 
way give rise to deformities of the trunk and extremities 
(curvatures). # 

The influences alluded to in the preceding observations are, 
doubtless, those which must be regarded as the most frequent 
and most important causes of malformations. But it is only 
rarely that we are able to point out in more minute detail the 
manner in which these causes operate. By mere general 
terms, as " increased or diminished energy of the formative 
power," such as were frequently employed by earlier 
authors, and which usually are nothing more than an abstract 
expression of that which the most superficial consideration of 
a malformation teaches, we must not hope to be able to 
explain the complicated causes of these changes, or to com- 
prehend their origin. There is here much untrodden ground 
for scientific investigators, and the most important results may 
be expected from their labours. 



* Several cases of this nature are collected by Henle, Op. cit. p. 9. 



THEIR CLASSIFICATION. 



487 



A perfect knowledge of the history of development is 
essential to the clear comprehension of the manner in which 
a certain cause, by exerting a disturbing influence upon the 
development, effects a certain malformation. This especially 
holds good in relation to the numerous forms of malformation 
in which, by arrest of development at an early stage, some 
parts of the foetus exhibit forms which correspond more or 
less closely with those of an earlier grade of development 
(arrest of formation) * 

Since malformations may affect the most different parts 
and organs of the body — sometimes one alone, sometimes 
several in connection with each other — their number becomes 
very great ; and, in order to regard them in a general point of 
view, it appears absolutely necessary to arrange them in certain 
classes. I regard the following classification as the most 
conformable to the objects of pathological anatomy : 

1st Class. Malformations, in which certain parts of the 
normal body are entirely absent, or are too small. — Monstra 
deficientia. 

2nd Class. Malformations produced by fusion or coales- 
cence of organs. Coalitio partium — Symphysis. 

3rd Class. Malformations, in which parts in the normal 
state united — as for instance, in the mesial line of the body 
— are separated from each other — Clefts, fissures. 

4th Class. Malformations, in which normal openings 
are occluded — Atresia. 

5 th Class. Malformations of excess, or in which certain 
parts have attained a disproportionate size — Monstra abun- 
dantia. 

6th Class. Malformations, in which one or many parts 
have an abnormal position — Situs mutatus. 

7 th Class. Malformations of the sexual organs — Herma- 
phroditism. 

To these true malformations I append also : 

* See Bischoff, Op cit. p. 892. 



488 



MALFORMATIONS. 



8th. Diseases of the foetus, and abnormal states of its 
envelopes. 

A classification of malformations presents numerous difficulties, and, 
in whatever manner it is attempted, must necessarily be very imperfect. 
In an anatomico-pathological point of view, it should, in my opinion, 
only claim to be in some degree a methodical register, affording an 
idea of the forms not merely actually occurring, but of all that can 
possibly occur, and thus enabling us to class a newly discovered malfor- 
mation with known allied forms. This appears to me to be accomplished 
by the above classification. I regard the objection which may be brought 
against it, that it is not perfectly logical, because the malformations of 
the genital organs form in it a class of their own, as unimportant ; for 
there are strong reasons in favour of their collection into a special class. 
For other objects other classifications may be more fitting, as, for ex- 
ample, that based on the causes of malformations, or on the influence 
which malformations exercise upon life, health, and on the civil useful- 
ness of the individual affected — a basis of classification which might be 
of more service to the medical jurist, but is of no value to us in this 
place. Accounts of other classifications, and critiques on them, may 
be seen in Geoffroy St. Hilaire and Bischoff. Op. cit. 

FIRST CLASS. 

MALFORMATIONS, IN WHICH CERTAIN PARTS ARE ENTIRELY ABSENT,. 

or are too small — Monstra deficientia. 

FIRST ORDER. 
DEFICIENCIES, IN THE STRICT SENSE OF THE WORD. 

We must here notice those cases in which certain parts of 
the body are altogether absent. This order comprises a great 
number of forms, of which the following constitute the best 
marked groups : 

1. Completely shapeless malformations (amorphus, Gurlt; 
anideus* Geoffroy St. Hilaire.) The monster presents the 
appearance of a more or less shapeless lump, with no indica- 
tion of definite organs ; it consists merely of integument, 
cellular tissue, serous fluid, fat, rudimentary bone, and vascu- 
lar ramifications, with an umbilical cord. It has been hitherto 



* From a nd ddog form ; hence, synonymous with amorphous. 



DEFICIENT MONSTERS. 



489 



rarely observed, and then usually co-existing with a normal 
twin ; hence it is probable that through the presence of the 
twin, the other germ has been at a very early period so 
much injured that this anomalous formation, void of every 
external and internal organ, has alone been developed from 
it ; of course, these monsters are not viable. 

See representations of these forms occurring in animals, in Gurlt, op. 
cit. PI. i.j fig. 1.," PI. xvi. fig. 1 to 4. ; Geoffroy St. Hilaire, op. cit. 
PI. xiii. fig. 1 and 2, vol. n. p. 528. — A case occurring in the human 
subject is described by Bland, in the Philosophical Transactions, 1781, 
vol. lxxi. p. 363, in a note. 

2. Malformations, which consist of only a more or less 
rudimentary trunk, while no signs of head or extremities exist. 
Like those belonging to the preceding group, they form exter- 
nally a shapeless mass, which, however, in the interior, besides 
fat, cellular tissue, rudimentary bone (vertebrae) and vessels, 
contains more or less decided traces of viscera. Malformations 
of this group are not viable. 

This form constitutes a division of the genus mylacephalus* of Geoffroy 
St. Hilaire. f In the human subject only one solitary case, observed by 
Vallisneri, appears to have been observed. OttoJ has figured and briefly 
described a case of this nature occurring in a calf. The monster co- 
existed with a well-formed twin, to whose secundines it was attached. 
Its origin therefore is, no doubt, to be explained in the same way as that 
of the first group. 

3. Malformations, in which the inferior half of the body 
is wanting, and only some parts of the upper half — as, 
for instance, the head— are present — trunkless monsters 
(acormus, Gurlt), The malformations belonging to this 
group consist of little else than a more or less rudimentary 
head, which, instead of neck and trunk, is furnished with a 
pouch-like appendage, containing rudimentary viscera, and 

* fxv\r], a mole in the womb, and cucityaXos. 

t Vol. ii. p. 488. 

X Op. cit. p. 3, PI. xxx. 



490 



MALFORMATIONS. 



pieces of bone of indefinite form. They are very rare, and are 
invariably accompanied by one or two well- developed children, 
so that, as in the case of the preceding groups, these are also 
to be explained by injury of the germ. These also are not 
viable. 

Cases of this kind are recorded in Meckel, vol. i. p. 57 ; Lycosthenes, 
chronicon prodigiorum ac ostentorum. Basil, 1557, p. 542 ; Delamarre, 
Journ. de med., chir., pharmac, t. xxxiii. 1770, p. 174 ; Rudolphi* 
in the transactions of the Berlin Akademie der Wissench. 1816, p. 99 j 
Nockher, medicin. Zeitung des Preuss. Vereins f. Heilkunde, 1837, 
No. 3; and Nicholson, de monstro hmnano sine trunco nato. Diss. 
Berol. 1837. 

4. Malformations, in which the head, and sometimes a 
part of the upper half of the body is wanting, whilst more 
or less of the inferior half of the body is present — acephalic 
monsters (acephalus). Numerous cases of acephalia have 
been observed in the human subject. They form a complete 
descending series of varieties. In the most perfect acephali 
the head alone is absent; indeed, rudiments of this organ 
exist, but they are concealed under the skin, and are only 
recognizable on an anatomical examination. The trunk is 
deficient to a certain extent ; the viscera are more or less 
developed ; the heart is commonly, but not always, absent, 
and the same may be said regarding the lungs. In other 
cases the superior extremities are wanting. In more defective 
formations of the kind, the greater part of the trunk is also 
absent, and the two inferior extremities, with the rudiment of 
a pelvis, alone exist. Indeed, there are instances recorded in 
which the acephalus has consisted of only a lower extremity 
(as in the case of a goat, described by Hayn). Acephali 
almost always occur in company with one or two perfect or 
less defective twins, whence it appears that in this case also 
the probable cause of the malformation is an injury of the 
germ, effected by the co-existing twin ; or sometimes, perhaps, 
hydrocephalus, in a very early period of pregnancy. The 
acephali are not viable. 



DEFICIENT MONSTERS. 



491 



The literature relating to acephali is very abundant, and the number 
of cases of this malformation which have been observed in the human 
subject may, perhaps, amount to 100 ; in animals they are less frequent. 
The most important information may be found in Meckel, vol. i. p. 140, 
&c. ; Fr. Tiedmann, Anatomie der kopflosen Missgeburten. Landshut, 
1813, with plates; E. Elben, de acephalis s. monstris corde carentibus. 
Berol, 1821 c. tab. (which contains an enumeration of most of the cases 
on record) ; and Geoffroy St. Hilaire, vol. n. p. 464. More recent 
cases are described by Pfotenhauer, de monstro acephalo humano. Berol. 
1835 ; Hildreth and Houston, in Valentin's Repertorium, 1837, p. 170; 
P. J. Gergens, Anat. Beschreib, eines merkw. Acephalus. Giessen, 
1830; J. H. Kalck, Monstr. acephal. hum. expos, anat. Berol, 1825 ; 
Herholdt, Beschreibung sechs menschl. Missgeburten. Kopenhagen, 
1830, p. 21 and 38 ; Otto, op. cit. p. 4, &c. On the circulation in the 
acardiac acephali, see Holland, " on the circulation in the acardiac 
foetus." Edin. Med. and Surg. Journal, 1845, vol. lxii. p. 156, &c. 

Geoffroy St. Hilaire subdivides the acephali into three genera : 1. 
True acephali, with perfect, or almost perfect thorax, which supports 
both upper extremities, or at least one of them. 3. Peracephali, without 
upper extremities. 3. Mylacephali, with very anomalous body, and 
either with very defective, rudimentary extremities, or with no limbs 
at all. 

5. Malformations in which not the whole head, but some 
of its component parts are wanting — monsters with defective 
head (perocephalus)* Malformations of this kind are very 
frequent in the human subject. They may be reduced to 
several subdivisions, some of which form well-characterized 
groups. 

a. The head may be present, but only as a mere rudiment. 
This group (par acephalus, pseudacephalus) is immediately 
allied to the acephali, and similar observations apply to it. 

Plates of this somewhat rare form are given in Gurlt, op. cit. PI. i. 
fig. 4, and in Geoffroy St Hilaire, PI. xi., who (vol. ji. p. 437, &c.) 
has also given the literature of the subject. He separates this group 
into three species : 1 . Paracephalus, with malformed, but voluminous 
head ; face distinct, with mouth, and rudimentary organs of sense ; the 
upper extremities present. 2. Omacephalus, with the head as in the 
preceding class, but the upper extremities absent. 3. Hemiacephalus, 

* From Trtjpog, deficient. 



492 



MALFORMATIONS. 



head very imperfect, formed by a shapeless tuberosity, with certain 
membranous appendages ; upper extremities present. 

b. The brain and greater part of the cranium may be 
absent. Brainless monsters (anencephalus, hemicephalus , 
microcephalus). Hemicephalia is comparatively frequent and 
presents different degrees : in the highest, not only the brain, 
but also the spinal cord is absent, and at the same time there 
exists a breach of continuity in the spinal canal (spina bifida); 
in a lower grade of malformation the spinal cord is present. 
In a still smaller degree, the malformation passes into the 
cranial fissure, presently to be noticed. Of the cranial bones, 
the os frontis, ossa temporum, parietalia and the greatest 
part of the os occipitis are commonly absent. Sometimes 
malformations of the trunk, or of the extremities are at the 
same time present. 

The cause of this malformation is commonly dropsy of the 
head ; in many cases, alarms, diseases and ill-treatment of the 
mother have preceded it, and Geoffroy St. Hilaire regards 
these as its exciting causes. Hemicephali notwithstanding 
the absence of brain are usually born alive ; some have sur- 
vived several hours, a few several days. 

Owing to the great frequency of these malformations (they form more 
than the third part of all cases of human monstrosities) their literature is 
very copious. We may especially refer to Meckel, op. cit. vol. i. p. 195, 
et seq. ; Geoffroy St. Hilaire, vol. n. p. 317, et seq. PI. 8 and 9 ; Otto, 
op. cit. (who describes upwards of fifty cases, and has figured several) ; 
Sommering, Abbildung und Beschreibung einiger Missgeburten, 1791? 
E. Sandifort, Anatomia infantis cerebro destituti, Lugd. Batav. 1784, 
with six beautiful plates ; Cerutti, rarioris monstri, in mus. anat. Lip- 
siensi adservati descr. anat. c. tab. 2. Lipsise, 1827; H. Mattersdorf, 
de anencephalia c. rariss. casus anenceph. post part, vivi exposit. Berol. 
1836; Krieg in Casper's Wochenschr. 1843, p. 543. Cases where the 
child lived for some time after birth, and was submitted to experiments, 
are described by Spessa, Gaz. med. Janv. 1833, and Miiller's Archiv. 
1834, p. 168, and by Panizza (Giornale del R. Institute Lombardo, 
1841, fasc. 3, and Oesterr. medicin. Wochenschr. 1S43, No. 9). See 
also Marshall Hall on the history of anencephali. 

Geoffroy St. Hilaire separates this group into two families with several 



DEFICIENT MONSTERS. 



493 



species, whose characteristics I shall notice, since they afford an excel- 
lent view of the most important forms which occur. 

A. PseudencephaM, containing in place of the brain, a soft, reddish, 
vascular protuberance. They may be divided into : 1. Nosencephali,* in 
which the skull is open only in the frontal and parietal regions, and the 
posterior fontanelle is distinctly present. 2. Thlipsencephali,f when the 
skull is opened not merely in the frontal and parietal, but also in the 
occipital region, and a distinct posterior fontanelle does not exist. And 
3. Pseudencephali in the strict sense of the term ; in which there is not 
merely the fissure of the skull, but the medullary canal is also widely 
cleft, and the spinal cord is absent. 

B. Anencephali, in which the brain is totally absent, without, as in 
the case of pseudencephali, being replaced by a foreign substance ; they 
are reduced into: 1. DerencephaliX in which not only the brain, but 
the spinal cord in the cervical region is also wanting ; the skull and 
upper part of the spinal canal being widely cleft. And 2. Anencephali 
in the strict sense of the word ; in which the brain and the whole of 
the spinal cord are wanting ; the skull and the spinal canal being widely 
opened. 

Some of these forms, as already mentioned, constitute the transition 
to the fissures which will be presently considered. 

c. Portions of the face — as the nose, eyes, facial bones, 
and at the same time more or less of the cranium — may be 
absent (aprosopus, microprosopus) . This class is reducible 
into many sub-orders, which are rare in man, but are frequent 
and comparatively abundant in animals. 

We must here place absence of the lower jaw, of the nose, of the 
eyes, of the mouth, &c, resulting from an extensive arrest of develop- 
ment. See Meckel, vol. i. p. 393, et seq. ; Sommering, Abb. und 
Beschreib. einiger Missgeburten, PI. 9 ; Otto, op. cit. No. 88, et seq. 
and Gurlt, op. cit. vol. n. p. 68, et seq. The deficiency of these 
organs individually, as absence of the eyes, of the eyelids, of the iris, 
of the ears, &c, whether occasioned by imperfect development or sub- 
sequent destruction, is noticed in the special department. 

These malformations also stand in the most intimate relation to some 
fissures and fusions, as for instance, with cyclopia. 

6. Malformations in which the whole body appears more 
or less defective, some parts being absent and others too 

* voqqs, disease. f 0\t\l>iQ, pressure, destruction. 

I Siprj, the neck. 



494 



MALFORMATIONS. 



small or unshapely (perosomus, Gurlt) : an indistinctly 
characterised group, whose occurrence is rare in man, hut 
more frequent in animals. They are not viable. 

Figures are given in Gurlt, op. cit. PI. in. fig. 5 and 6 ; PI. iv. fig. 
1 and 2. 

7. Malformations in which the trunk is defective, and too 
short, from the absence of one or more vertebrae ; the head 
and limbs being normal (perocormus — oligospondylus, 
Gurlt). They arise either from an original defect in the for- 
mation of the vertebrse or from fusion of several into one. In 
man they are never observed, and only rarely in animals. 
These malformations do not affect life. 

Gurlt, op. cit. PI. ii. fig. 4 ; Otto, op. cit. No. 213, et seq. Ab- 
sence of the tail in animals belongs to this group. 

8. The extremities may be deficient ; all the limbs may be 
absent, or two or only one, or merely portions of the extre- 
mities may be wanting. The head and trunk may in this 
case, be either normal or abnormal (peromelus, Gurlt). This 
group may be reduced to several subdivisions ; the forms 
included in it arise partly through original abnormalities of for- 
mation — the germinal elements for the extremities being either 
not evolved at all, or experiencing an arrest at some stage of 
the development; and partly through mechanical agencies — the 
extremities when perfected or in the act of forming, becoming 
atrophied from mechanical causes, as for instance, constric- 
tion by the funis. Such malformations are not unfrequently 
hereditary. The subjects of them are viable. 

For the literature and illustrations of this group, we may refer to 
Meckel, vol. i. p. 748 et seq. where most of the earlier cases are 
collected; Otto, op. cit. p. 134 ; Herholdt, Beschreibung sechs menschl. 
Missgeb. p. 59 ; and Cruveilhier, Anat. pathol. livr. 28, Plate i. 

Geoffroy St. Hilaire names the higher grade of these malformations 
Ectromeles* (vol. n. p. 307 et seq.) and reduces them into 3 genera. 



* etcTpojEtv, to cause to abort. 



DEFICIENT MONSTERS. 



495 



1 . Phocomeles* in which hands and feet appear to exist independently 
of arms and legs, and to he inserted immediately into the trunk. 

2. Hemimeles, in which the upper or lower extremities are very defec- 
tive — mere stumps — and the fingers and toes are entirely wanting or are 
very imperfect. 3. Ectromeles in the strict signification of the term ; 
in which the extremities are nearly or altogether absent. The slighter 
degree of the malformation, where only one or more fingers or toes are 
wanting is named by GeofFroy St. Hilaire Ectrodactylie (vol. i. p. 676). 
It is sometimes hereditary and may be referred to a defective develop- 
ment ; since the germs for the hand and foot are at first simple, and do 
not until a later date become divided into the individual fingers and toes. 

The cases in which certain internal organs or parts of them 
are absent — a class of malformations which are commonly 
first discovered by anatomical examination — will be found in 
the special part. 

SECOND ORDER. 
ABNORMAL DIMINUTIVENESS OF PARTS DWARFISH STRUCTURE. 

Here we have all the organs of the body present, but some of 
them too small. This arises either from a primitive tendency 
of the germ or from a subsequent arrest of the development of 
parts which are in process of forming, or from atrophy of 
parts already perfected. The individuals affected with it are, 
in general, viable. 

1. General dwarfishness {nanosomus,f Gurlt ) If the 
entire body with all its parts is smaller than common, the indivi- 
dual constitutes a dwarf, whose component parts are more or 
less proportionate. This state, (as is well known) is not unfre- 
quent, and the individuals affected with it are always viable ; it 
is often hereditary, or, at least, is extended to several children 
of the same parents. 

For cases see Otto, patholog. Anatomie, vol. i. p. 19, or South's 
translation, p. 21, and GeofFroy St. Hilaire, vol. i. p. 140, et seq. 



* (pwicri, a seal ; in consequence of the similarity of the extremities 
to those of that animal. 
ivavos, a dwarf. 



496 



MALFORMATIONS. 



where many instances are collected, and a few described in detail. An 
account of a family of dwarfs may be seen in Casper's Wochenschr. 
1842, p. 705. 

2. Dwarfish head, (nanocephalus, Gurlt). The whole 
head or certain parts of it being too small, while the trunk 
and extremities are normal. The higher grades of this group 
are allied to the perocephali, namely to the microprosopi. 
In man they are rare, but are almost always viable. 

To this group we must refer arrested development of the lower jaw, 
Geofiroy St. Hilaire, vol. i. p. 259. 

3. Dwarfish trunk, {nanocormus, Gurlt). The trunk, 
with or without extremities, being two small, whilst the head 
possesses its normal size. 

4. Dwarfish limbs, (nanomelus, Gurlt). Some or other 
part of an extremity being too small, and the whole limb 
being therefore too short, but yet no part of it being absent. 
Head and trunk are generally normal. This form is allied, as 
a lower degree, to the peromeli. 

Cases belonging to the preceding groups are given in Geofiroy St. 
Hilaire, vol. i. p. 251, et seq. 

SECOND CLASS. 
MALFORMATION FROM COALESCENCE OF ORGANS. 

Coalitio partium — Symphysis. 

Parts which normally lie together unconnected, (usually in 
the mesial line of the body), may approximate more close- 
ly than in the normal state, and form a coalition; there 
thus arises a new and peculiar formation. In many 
cases this coalescence is only possible in consequence of 
the atrophy or total absence ' of parts, which in the normal 
state separate the organs here united. In this way many of 
the cases included here are in the closest alliance with the 
preceding class. We have the following well characterized 
groups. 

1. Malformations by coalescence on the head. These 



MALFORMATION BY COALESCENCE. 



497 



reduce themselves into two subdivisions according as the 
upper part of the face with the eyes, or the lower part of it 
(the mouth), is the seat of the malformation. 

a. Coalescence of the eyes {cyclopia, monophthalmus). 
The eyes are very nearly approximated or even amalgamated 
in the mesial line of the face. The nasal cavities and some of 
the bones of the superior half of the face are more or less defi- 
cient. Moreover, a proboscis frequently exists above the 
eyes. The mouth is large and irregular, or altogether absent. 
The varieties of this malformation are very numerous. 

Cyclopia may be regarded as an interruption in development ; 
the special explanation of its origin, however, differs accord- 
ing to the different view which is taken of the normal deve- 
lopment of the eyes. If we assume with Huschke, that the 
two eyes originate from one primitive rudiment, which only 
at a later period becomes divided by the intrusion of the nose 
and face, the deficient development of the last named parts, 
is the cause of the non-separation of the eyes. If, on the 
contrary, we assume with BischofF that the two eyes are ori- 
ginally distinct, then the development of cyclopia, appears to 
require an amalgamation of the germinal elements of the two 
eyes. Whichever of these views we advocate, cyclopia, in an 
anatomical point of view, always appears as a coalescence of 
organs, which in the normal condition are apart from each 
other; and so far belongs to this place, although, at the 
same time, it is most intimately allied to the monstra defi- 
cientia. 

Cyclopic malformations in the human subject are not very 
rare ; and in many animals, for instance in swine, they are 
frequent. Although usually born alive these monsters are not 
viable. 

Illustrations and descriptions are given in Cruveilhier, Anat. pathol. 
livr. 33, PL vi. ; Otto, op. cit. p. 83 et seq. ; Knape, Monstri hum 
maxime notabil. descr. anat. Berol. 1823. See also J. F. Meckel, iiber 
die Verschmelzungsbildungen, in his Archiv. vol. r. 1826, p. 238 ; 
Seiler, iiber Cyclopie, Dresden, 1833; Vrolik, over den Aard en oor- 
sprong der Cyclopie, Amsterd. 1834, (or the abstract in Midler's 

VOL. I. K K 



498 



MALFORMATIONS . 



Archiv. 1836, Jahresber. p. 177, et seq.) ; and Geoffroy St. Hilaire, 
PI. vn. and vol. n. p. 375, &c, and who names the whole group Cycloce- 
phaliens, and makes the following subdivisions, which, at the same time, 
serve as a view of the principal forms : 

a. There may be two orbits which, however, are very closely approxi- 
mated. 1 . Ethmocephalus ,* with two eyes distinctly apart, but very 
close ; the organ of smell atrophied, and occurring only in a rudimen- 
tary form, which appears externally as a proboscis above the orbits. 
2. Cebocephalus ,f with two very closely approximating, but yet decidedy 
separated eyes ; the organ of smell atrophied, no proboscis. 

B. Or there may be one orbit. 3. Rhinocephalus, with two adjacent eyes, 
or one double eye in the mesial line ; the organ of smell being atrophied, 
and forming a proboscis. 4. Cy otocephalus, with two adjacent eyes, 
or one double eye in the mesial line ; the organ of smell atrophied, 
but forming no proboscis. 5. Stomocephalus, with two adjacent eyes 
or one double eye in the mesial line ; the organ of smell atrophied, and 
forming a proboscis ; the jaw rudimentary, and the mouth very imper- 
fect or entirely wanting. 

In reference to the coalescence of the eyes, we may distinguish the 
following forms : 1 . The eyes may be double, completely asunder, and 
each with its own eyelid, but closely approximating. 2. Two perfectly 
developed eyeballs may be in contact, and included within one common 
upper and lower eyelid. 3. The two eyeballs may be more or less 
amalgamated, but contain several internal parts doubled. 4. Only one 
eyeball may be apparent externally. 5. The eye may not be apparent 
externally ; indeed sometimes it is absent altogether. 

h. The coalescence may be chiefly limited to the inferior 
half of the face, (monotia, agnathus, otocephalus). The 
inferior, and more or less of the superior maxilla, with the 
bones in immediate connection with them may be wanting. 
The mouth is then very small or altogether absent, the ears 
approach each other under the face or perhaps even unite. 
This group is closely allied with that of cyclopia, and the two 
malformations are not unfrequently combined ; consequently 
many cases belonging to this are referred by some to cyclopia. 
There can be no doubt that the cause of this malformation is 
to be sought in a deficient development of the parts of the 

* ridfiog, the root of the nose, 
t Krj(3oQ, an ape. 



MALFORMATIONS OF COALESCENCE. 499 



face, namely of those which form the commencement of the 
alimentary canal. 

Some of the literature cited in reference to cyclopia is equally ap- 
plicable here ; we may also mention, Otto, op. cit. p. 112, et seq. and 
Geofrroy St. Hilaire, vol. n. p. 420 et seq. The latter arranges this 
group, which he names Otocephaliens, under the following subdivisions : 

a. With two distinctly separated eyes. 1. Sphenocephalies, the ears ap- 
proximating under the face and uniting; jaw and mouth evident. 

b. With only one eye or two united in one socket. 2. Otocephalus, 
the ears approaching each other under the face or uniting ; jaw and 
mouth obvious ; no proboscis. 3. Aedocephalus ,* the ears approximat- 
ing under the face or uniting ; the jaw atrophied ; no mouth ; a proboscis 
over the eye. 4. Opocephalus,\ the ears approaching each other under 
the face or uniting; the jaw atrophied; no mouth; no proboscis. 

c. The eyes absent. 5. Triocephalus ,% the ears uniting under the face 
or approximating ; jaw atrophied ; no mouth ; no proboscis. The latter 
in its higher grade forms the transition to the acephali. 

2. Coalescence of the inferior half of the body, namely 
of the lower extremities, (monopodia, sympodia). The 
pelvis and the organs lying within it, are here incompletely 
developed ; the lower extremities coalescing, and at the same 
time more or less atrophied. There are different degrees of 
this condition. In the lowest the two inferior extremities 
coalesce into one common limb which supports two feet ; in 
a higher, they are united to one limb and one foot ; finally, in 
the highest, they form together only an undefined caudiform 
mass. This malformation depends upon a deficient develop- 
ment of the lower end of the trunk, whereby the germs of the 
inferior extremities approximate too closely, and thus become 
amalgamated. The subjects of this malformation are not 
viable. 

* cuctota, the organs of generation ; the proboscis having been re- 
garded by some of the early observers as a penis. 

f the eye ; since the eye with its appendages here forms nearly 
the whole head. 

X Since three principal parts of the head — the mouth, nose, and eyes— 
are absent or deficient. 

K K 2 



500 



MALFORMATIONS. 



From the rather copious literature of this subject, I may especially 
notice : Cruveilhier, Anat. pathol. liv. 33, PI. v and vi, andliv. 40, PI. vi ; 
Otto, op. cit. p. 153 et seq. ; idem, Monstr. hum. sex anat. et path, 
disquis. Francofurt, 1811; A. Kaw Boerhaave, Hist. anat. infantis, 
cujus pars corpor. infer, monstrosa. Petropol. 1754 ; Rossi, Diss. Jenens. 
1800; Kohler, Diss. Jenens. 1831 ; Maier, Dissert. Tubingens, 1837 ; 
M.M. Levy, de sympodia. Diss. Havniee, 1833 ; and Huesker, de vitiis 
syngeneticis, adjecta monstri sireniformis descr. Gryphise, 1841. 

Geoffroy St. Hilaire (PI. v, and vol. n. p. 237), names these malforma- 
tions, Symeliens, and arranges them, according to the degree of the 
deformity, into three subdivisions : 1. Symeles, with the limbs amalga- 
mated, but otherwise almost perfect, terminating in a double foot, 
whose sole is directed anteriorly. 2. Uromeles, with the limbs amalga- 
mated, very imperfect, terminating in a simple foot which is almost 
always imperfect, and has the sole directed anteriorly. 3. Sirenomeles, 
when the two lower extremities are completely fused together, and are 
in the highest degree imperfect, terminating in a stump or point, without 
evident foot. 

3. To these we may add certain other amalgamations, whose 
existence, however, does not affect viability. The principal 
and most frequent of these are : 

Coalescence of the fingers and toes (syndactylus, Gurlt). 
This form occurs in two degrees : in the lower degree, merely 
the soft parts — muscles, cellular tissue, and skin, or the latter 
alone — are united, and the bones are double : in the higher 
degree, the phalanges are also amalgamated. This malforma- 
tion is sometimes complete on both hands and feet at the 
same time, but more frequently it is confined to certain pairs 
of fingers or toes. # It is to be viewed merely as an anatomical, 
not as a physiological coalescence, since the germinal matter 
of the hands and feet is simple, and only at a comparatively 
advanced period of development is divided into individual 
fingers and toes. 

The congenital fusion of those viscera which normally 
occur in pairs, as the kidneys and ovaries, are, for the sake of 
avoiding repetition, noticed in the special part. 

* Cases with illustrative plates are given in Otto, op. cit. p. 312, 
et seq. 



MALFORMATIONS DEPENDING ON FISSURES. 501 



THIRD CLASS. 

MALFORMATIONS, IN WHICH PARTS NORMALLY UNITED ARE SEPARATED 
FROM EACH OTHER FISSURES. 

In this class of malformations, parts which normally are 
united appear cleft at some spot in the mesial line. The 
manner in which these malformations originate, can be very 
clearly shown by the history of development, although the 
causes giving rise to them are not very obvious. The cavities 
for the brain and spinal cord on the one hand, and of the 
chest and abdomen on the other, are known to be produced in 
the following manner ; the parts of the embryo, at first forming 
laminae, rise on each side, and gradually approach each other, 
uniting in the mesial line of the body. If this union does 
not take place, or if, having already occurred, separation 
through any cause (as, for instance, the excessive accumulation 
of water in a cavity of the body) ensues, a fissure arises. It 
is usually accompanied with a protrusion of those viscera which 
normally lie within the fissured cavity, or if the cleft involves 
only a part of the structures (muscles and bones) forming the 
wall, whilst the external skin or internal serous coat remains 
undivided, a rupture (hernia) occurs. In a similar manner 
we have smaller orifices as congenital malformations ; open- 
ings, as the foramen ovale of the heart, the ductus hot alii, 
and the urachus, which in the normal state become closed at 
a later period of foetal life, or immediately after birth, do not 
close, but remain patent. The higher grades of the fissures 
are closely allied to some groups of the first class of malfor- 
mations. 

On fissures generally, and their individual forms, the reader may con- 
suit C. Meyer, de fissuris hominis mammaliumque congenitis. Dissert. 
Berol. 1835 ; and E. A. W. Himly, Darstellung des Duaslismus am 
normalen und abnormen menschlichen Korper. Hannover, 1829. 

1. Fissures on the head (schistocephalus* Gurlt), are 



* (T^LITTOS Cleft, 



502 



MALFORMATIONS. 



resolvable into distinct groups, which occur in part singly, and 
in part in connection with each other. 

a. Fissure of the cranium. The higher degrees, where 
the skin, bones, and membranes of the brain are divided, and 
the brain, in a more or less atrophied condition, is exposed, 
are allied to hemicephalia. In the lower degrees, the fissure 
is limited to the cranial bones; the integument of the head being 
present, and forming a hernial sac, in which the brain lies ex- 
ternally to the skull ; this sac commonly contains also a large 
quantity of serous fluid (hydrencephalocele, Otto). In these 
cases we frequently observe a union of the placenta with the 
head. 

The cause of cranial fissure is certainly, in the majority of 
cases, hydrocephalus. Individuals with cranial fissure are not 
viable ; even those affected with a slighter degree of the 
malformation die shortly after birth. 

For cases, consult Meckel, vol. i. p. 301, &c. ; Otto, op. cit. p. 38; 
G. Frederici, Monstr. human, rariss. Lipsiae, 1737. c. tab.; Sommer- 
ing, Abbildung u. Beschreibung, &c. PI. n. ; and C. E. Rudolphi, 
Monstror. trium praeter natur. cum secundinis coalitor. disquis. Berol. 
Geoffroy St. Hilaire* names the whole group Exencephaliens, and reduces 
them to the following subdivisions : 1 . Notencephalus ; when the cranial 
fissure exists in the occipital region, the greater part of the brain lying 
exteriorly, and occupying a position posterior to the skull upon the back. 
2. Proencephalus ; when the fissure is in the frontal region, the greater 
part of the brain lying anterior to the skull. 3. Podencephalus ;f when 
the skull is incomplete on its upper wall, and the greater part of the 
brain is exterior, in a position superior to the skull. 4. Hyperencephalus ; 
when the roof of the skull is entirely absent, and the brain projects to a 
great extent ; this is the highest degree, and is immediately allied to 
hemicephalia. Geoffroy St. Hilaire adds two other species, which are 
characterized by the co-existence of a cleft in the spinal canal. 5. 
Iniencephalus ;% when the greater part of the brain lies within the cranial 
cavity, but in part also exterior to it, behind, and somewhat beneath the 
skull, which is fissured in the posterior region of the head. 6. Exen- 

* Vol. ii. p. 291, &c. and PI. x. 

f 7vovs, a foot ; the brain being connected to the cranial cavity by a 
species of pedicle. 

t Iviov, the back of the head. 



MALFORMATIONS DEPENDING ON FISSURES. 503 



cephalus ; when the greater part of the brain is out of the cranial 
cavity, and lies behind the skull, most of whose upper wall is wanting. 

b. Fissures in the facial part of the head occur in diffe- 
rent degrees, such as fissures of the whole face, of the nose, 
of the upper lip, and of the palate. On account of their 
more frequent occurrence, and their importance in relation to 
surgery, the two latter malformations possess an especial 
interest, since those affected with them are not only viable, 
but their condition admits of amelioration. 

In the lowest degree, the cleft or hare-lip, the upper lip is 
divided either singly in or beside the mesial line (constituting 
a single hare-lip), or on both sides of the raphe, so that 
between the two fissures there intervenes an atrophied and 
usually conical central portion (the double hare-lip). In 
the higher degrees, the alveolar portion of the upper jaw also 
takes part in the fissure. In cleft-palate or wolfs-jaw 
(rictus lupinus) there is a fissure of the hard or soft palate, 
or of both together, either singly in, or on one side of the 
mesial line, or, as in double hare-lip, on both sides. Hare- 
lip is not unfrequently combined with cleft-palate. 

The origin of these malformations is referable to an 
arrest of structure. At an early foetal period, the palate 
and superior maxillary bones are separated by the os inter- 
maxillare. If the development remains stationary, at a 
condition corresponding to this stage of evolution, and the 
normal union is not established, there arises double cleft- 
palate or double hare-lip ; if, again, union takes place on one 
side only, single cleft-palate or hare-lip results. The occurrence 
of the latter in the mesial line is, therefore, always only 
apparent. 

For cases, consult Meckel, vol. i. p. 521 ; Geoffroy St. Hilaire, vol. i. 
p. 581 ; Otto, op. cit. p. 288, &c. ; Caspar, de labio leporino. Got- 
ting. 1837 ; Leuckart, Untersuch. uber das Zwischenkieferbein des 
Menschen in s. norm, und abnormen. Metamorphos. Stuttgart, 1840. 

c. Fissures of individual organs and parts of the head, 
as extensive separation of the lips, splitting of the cheeks, 



504 



MALFORMATIONS. 



of the eustachian tubes, of the cavity of the tympanum, of 
the tongue, division of the iris and choroid coat of the eye 
(coloboma iridis), are described in the special part. 

2. Fissures on the trunk and neck (schistocormus, Gurlt), 
appear under very different forms, according as the cleft occurs 
on the neck, thorax, abdomen, the pelvis, or the arches of the 
vertebrae. As in the fissures on the skull, so in these cases, 
the viscera are frequently protruded, and, according as they 
lie exposed, or are still covered with a part of the membra- 
nous investments, form either a prolapse or a hernia. 

a. Fissures on the neck (fistula colli congenita). Their 
origin is due to an arrest of formation; the respiratory 
or visceral clefts, which during the formation of the embryo 
appear on the cervical region, not uniting at an early stage, as 
in the normal condition, but remaining open at certain spots. 

Literature. Fr. M. Ascherson, de fistulis colli congenitis. Berol. 
1832 ; Kersten, de fist. c. c. Magdeb. 1836 ; Zeis in v. Amnion's Mo- 
natschr., vol. n. part 4 ; J. Heine, de fist, colli congen. Diss. Halens. 
Hamburg, 1840 ; Munchmeyer, in the Hannover. Annal. 1844. 
part i. 

b. Fissures of the spinal column, i. e. of the vertebral 
arches, (spina bifida), occur in very different degrees, from 
splitting of the entire spinal canal, which commonly exists in 
connection with hemicephalia, to the division of the arch of 
one or more vertebrae, in which case the fissure frequently 
remains covered by the membranes and skin. It is either an 
original arrest of structure, or the effect of dropsy of the 
vertebral canal (hydrorhachis). 

The literature of this subject is very abundant ; we may especially 
notice Meckel, vol. i. p. 347, and Geoffroy St. Hilaire, vol. i. p. 615. 
The reader may also consult Sandifort, Mus. anat. vol. iv. pi. 65 and 
66 ; Otto, op. cit. p. 282 ; Cruveilhier, liv. vi. pi. 3 ; and liv. xvi. pi. 4; 
Kiister, de spina bifida. Gryphiae 1842; and Anderseck, exercit. anat. 
circa monstra duo hum. spina bifid, aff. Vratislaviae 1842. 

c. Fissures of the thorax and abdomen occur either 
alone or together, 



MALFORMATIONS DEPENDING ON FISSURES. 505 



Thoracic fissures ( fissura sterni) resolve themselves into 
those in which, besides the sternum, the skin is also sepa- 
rated — in which case the thoracic viscera are exposed, and 
form a prolapsus (prolapse of the heart or lungs) ; and 
into those in which the integument is not cleft, and where 
the protruded thoracic viscera are covered by it (hernia pec- 
tor alis) . 

The same holds good regarding abdominal fissures. In 
the lowest degree, the umbilicus alone is open and the 
abdominal viscera, to a greater or less degree, protrude 
through it (congenital umbilical hernia — exomphalus) ; in 
the highest degree the abdominal walls are completely cleft, 
and the viscera are more or less exposed and protruded, 
forming a prolapsus. 

In some instances the fissure is limited to the lower part 
of the abdomen, and especially affects the bladder (prolapsus 
vel inversio vesicce urinaria). It generally happens in this 
case, that the urethra is also cleft on its upper side (epi- 
spadias). 

The higher degrees of this malformation are incompatible 
with viability. 

The literature of this subject is given in Meckel, vol. i. p. 93 ; 
Geoffroy St. Hilaire* names the whole group Celosomiens,-\ and reduces 
them to the following subdivisions : 

A. The cleft limited to the abdomen. 1. Aspalosomus ,\ the fissure and 
eventration extending chiefly upon the lower part of the abdomen ; the 
urinary apparatus, genitals, and rectum, opening externally by three dis- 
tinct orifices. 2. Agenosomus,§ the fissure and eventration chiefly in the 
lower part of the abdomen ; urinary and sexual apparatus absent or very 
rudimentary. 3. Cyllosmus,\\ the fissure and eventration lateral, chiefly in 
the lower part of the abdomen ; the inferior extremity of the side affected 
with the fissure, absent or very little developed. 4. Schistosomus, the 

* Vol. ii. p. 264, &c. PI. vi. 
t KrjXrj, a hernia. 
+ a<T7ra\a£, a mole. 

§ a and yew aw, without generative organs. 
|| kvWos, crooked. 



506 



MALFORMATIONS. 



fissure and eventration extending over the entire length of the abdo- 
men ; the lower extremities absent, or very little developed, so that the 
body appears as if truncated inferiorly. 

B, The fissure extending also to the thorax. 5. Pleurosomus , the fissure 
somewhat lateral, with eventration extending chiefly upon the upper part 
of the abdomen, and upon the chest ; the upper extremity of the fissured 
side being more or less atrophied. 6. Celosomus, complete fissure on 
one side, or in the mesial line, with atrophy or total absence of the 
sternum, and prolapse of the heart. Plates and descriptions of hernia 
umbilicalis congenita are given in Cruveilhier, Anat. pathol. livr. xxxi. 
pi. 5, and Otto, op. cit. p. 294. On ectopia of the heart, see Cerutti, 
Rarior. monstr. descr. anat. Lips. 1827 ; C. Weese, de cordis ectopia. 
Diss. Berol. 1818 ; and H. J. Haan, de ectopia cordis. Diss. Bonn. 
1825. On prolapsus vesica urinaria, see Sandifort, Mus. anat. vol. iv. 
pi. 67, fig. 2 ; J. Schneider, der angeborne Vorfall der umgekehrten 
Urinblase, with plates. Franc, a. M. 1832. (Reprinted from Siebold's 
Journ. f. Geburtshiilfe) with copious literature; and Garvens, Inversio 
vesicae urinaria?. Dissert. Halens. 1841. 

d. Fissure of the urethra inferiorly (hypospadias), usually 
accompanied with fissure of the scrotum, together with the 
formation of a cloaca, in which the orifices of the urinary and 
sexual organs and of the rectum meet in a common receptacle, 
is discussed under the head of Hermaphroditism. 

All or the greater number of the above fissures sometimes 
occur to the same person. # 

3. In this class we must include other fissures, which at 
first sight are scarcely, or not at all, perceptible, and are only 
to be recognised by a careful anatomical examination — fissure 
of the lungs, spleen, liver, thymus gland, kidneys, or 
pancreas ; also the abnormal patency of certain canals or 
orifices, which in the normal state are closed — as of the 
urachus, the ductus venosus Arantii, the duct, arteriosus 
Botalli, and the foramen ovale of the heart. These will 
engage our consideration in the special part. 



* Tiedemann, Anatomie der Kopflosen Missgeb. PI. iv. 



MALFORMATIONS OF EXCESS. 



507 



FOURTH CLASS. 

MALFORMATIONS IN WHICH NORMAL OPENINGS ARE CLOSED. — Atresia.* 

Since most of the malformations belonging to this class 
stand in relation to individual organs, and will hence be more 
particularly described in the special part, we shall here content 
ourselves with a specification of the principal forms. Their 
origin can usually be referred to an arrest of structure.f The 
higher grades alone are incompatible with life. 

1. Atresia on the head (atretocephalus Gurlt). These 
include congenital occlusion of the mouth, of the nostrils, 
of the external auditory foramen, of the palpebral fissure, and 
of the pupils. 

Cases are recorded in Meckel, vol. i. pp. 396, 401, 407 ; in Geoffroy 
St. Hilaire, vol. i. p. 525, et seq. ; and in Otto, p. 315. 

2. Atresia on the trunk {atretocormus Gurlt) are, chiefly, 
imperforate conditions of the anus, of the urethra, and of the 
vagina. Their higher grades are always combined with 
malformations of internal organs — of the intestinal canal, or of 
the generative system. 

Meckel, vol. i. pp. 591, 655, 662; Geoffroy St. Hilaire, vol. i. 
pp. 521, 533 ; Otto, p. 316 ; Cas. deChonski, devitio quod primse form, 
infer, potiss. tubi intest. partem et vesic. urin. spectat. Diss. Berol. 
1837. 

FIFTH* CLASS. 

MALFORMATIONS OF EXCESS, OR IN WHICH CERTAIN PARTS HAVE A 

disproportionate size. — Monstra abundantia. 

This class may be arranged in two divisions according 
as certain parts are too large, or there are supernumerary 
organs. 

* arprjTos, imperforate. 

t Bischoff in Wagner's Handworterbuch, vol. i. p. 905. 



508 



MALFORMATIONS. 



FIRST ORDER. 
ONE OR MORE PARTS DISPROPORTIONATELY LARGE. 

In many cases the whole body is too large, but the 
parts are more or less proportionate. These cases present 
themselves under very different forms : in some instances, 
the individual, even at birth, is larger than usual ; in others 
he becomes prematurely developed after birth ; and again in 
others he attains to an abnormal size, and becomes a giant, 
or excessively corpulent (polysarcia). 

The greater number of these abnormalities do not properly belong to 
congenital malformations, and consequently demand merely a passing 
notice. The tallest men, respecting whose heights we possess trustworthy 
statements, measured eight and a half feet, or perhaps a little more. 
Cases have been observed in which the growth of the beard and 
other indications of almost full development have occurred in 
children seven years of age, and even younger. Excessive 
corpulence has been chiefly observed in England ; cases are recorded in 
which individuals have attained a weight of six hundred and fifty pounds. 
For further details on this subject we must refer to Meckel, op. cit. 
vol. ii. part i. p. 2, et seq. ; and Geoffroy St. Hilaire, vol. i. p. 168. 

In a similar manner, individual parts of the hody may be 
too large ; this, however, is rarely a congenital malformation, 
but more commonly local hypertrophy acquired after birth. 

The most frequent of the congenital malformations belonging to this 
class is a disproportionate size of the head, from the accumulation of fluid 
in the cranium — hydrocephalus congenitus. For cases see Geoffroy 
St. Hilaire, vol. i. p. 253, &c. 

SECOND ORDER. 
ONE OR SEVERAL SUPERNUMERARY ORGANS. 

This order presents a very great number of varieties, from 
the simplest cases, in which a single joint of a finger is super- 
numerary, to those of a highly complicated nature, where two, 
or even three bodies are united by some one point — twin ot 
triplet monsters. 



SUPERNUMERARY ORGANS. 



509 



Great difference of opinion has prevailed respecting the 
causes and mode of origin of these malformations with super- 
numerary parts. 

According to some, they arise by a coalescence of two 
separate germs, while according to others, they depend on a 
furcation of a single germ. 

Although, at present, it is impossible to decide with cer- 
tainty on either of these views, yet in the majority of cases, 
(with certain exceptions to be presently mentioned,) the latter 
appears to me by far the more probable. 

The chief arguments in favour of the latter view are the following : 

1 . The organs that are united are always similar organs : head with 
head, thorax with thorax, &c. ; a fact that can only be explained in a 
very forced manner by the assumption of a coalescence of two germs. 

2. There is a complete transition from the cases where two almost 
perfect individuals are attached at only a circumscribed spot of the body, 
to those where one individual bears only some trivial supernumerary parts, 
or other malformation, as, for example, fissure of the skull ; in short, to 
cases whose origin no one would ascribe to a coalescence of two germs.* 

3. Finally, it is totally incomprehensible, how, in the case of two 
separated germs or ova, of which each must have its own membranes, a 
union of two embryos can take place ; and it is just as little to be com- 
prehended how, in such a union, often more than the halves of the two 
systems can be so intimately fused together, as we sometimes find to be 
the case. These are the principal reasons which lead me to agree in the 
opinion, that all twin and triplet monsters, with the exception of the 
cases of foetus in fcetu, proceed from a simple germ, or ovum. 

The question : how and from what causes does it happen that a mal- 
formation with supernumerary parts is produced from one ovum ? can 
only be answered by experience, and the materials necessary to this 
reply will doubtless be furnished to us by future observers. At present, 
little more than the following can be said upon the subject. In some 
cases the ovum or the germ is malformed ab origine (the yolk of abnor- 
mal form — ovum in ovo), in others it becomes, after impregnation, 
so affected by causes still unknown to us, that excessive nutrition of 
particular portions of it ensues, and hence supernumerary parts are 

* Sommering has pointed out this fact very convincingly in certain 
cases. See the vignette on the title-page of his Beschreibung und 
Abbildung einiger Missgeburten. 



510 



MALFORMATIONS. 



formed. Sometimes, finally, the excessive number of parts is only- 
apparent, and is founded upon an arrest of development. On these 
points the reader will find further details in Meckel, vol. n. part i. 
p. 11, &c, and in Bischoff, op. cit. p. 909, &c. 

The malformations belonging to this order may be arranged 
in two subdivisions, according as the head and trunk are 
single, and only certain portions of them, or particular limbs 
and their parts are supernumerary ; or as the head and trunk 
are double or even triple. 

I. MALFORMATIONS IN WHICH THERE ARE SUPERNUMERARY PARTS, 
BUT A SINGLE HEAD AND TRUNK. 

Most of the malformations belonging to this subdivision 
are noticed in the special part, so that in this place a mere 
specification of them is sufficient. 

1 . Supernumerary parts on the head. We may have mul- 
tiplication of the cranial bones, as double frontal bone, 
ossa wormiana (which are properly formations of arrest) ; 
duplication of the lower jaw and of the tongue ; supernume- 
rary teeth ; and in animals, supernumerary horns. 

2. Supernumerary parts on the trunk, as an increased 
number of vertebrae ; the formation of a tail in the human 
subject ; # supernumerary ribs, muscles, and mammae. 

3. Supernumerary parts on the limbs. Supernumerary 
fingers and toes in the human subject are by no means rare, 
and sometimes appear to be hereditary. 

Six fingers on one hand are not unfrequent ; a case in which there 
were seven fingers on one hand, and eight toes on one foot is given in 
Geoffroy St. Hilaire, PI. in. ; several cases are also given in Otto, 
p. 267, &c. 

Supernumerary extremities with a single head and trunk, 
very rarely occur in man, but are comparatively frequent in 
animals. These cases form the transition to the second 
division. 

* See Meckel, vol. i. p. 385 ; and Geoffroy St. Hilaire, vol. i. p. 736. 



DOUBLE MONSTERS. 



511 



Supernumerary parts in the intestines, as for instance, 
supplementary spleens, are noticed in the special part. 

II. MALFORMATIONS WITH SUPERNUMERARY PARTS, AND MORE THAN 
ONE HEAD OR TRUNK. 

The malformations belonging to this division form the 
so-called double or twin monsters (monstra duplicia, 
m. bigemina), and triplet monsters (m. trigemina). They may 
be regarded (anatomically, but not physiologically), as two 
individuals, whose bodies are adherent, and, to a greater or 
less extent, fused together in a very symmetrical manner, by 
the coalition of corresponding parts. 

The literature on the general relations of these malformations is very 
abundant. We may especially notice Meckel, op. cit. vol. n. p. 38, 
&c. ; Meckel, de duplicitate monstrosa, 1815; Burdach, Sechster 
Bericht von der anatomischen Anstalt in Konigsberg, 1823 ; Barkow, 
Monstra animalium duplicia per anat. indagata, Lipsise, vol. i. 1826, 
vol. ii. 1836; and Bergholz, de monstro dupl. per implantat. ac de 
duplicitate, Berol, 1840. 

These malformations are further divisible into two groups : 
in the one, the united individuals are both equally developed, 
double monsters by coalition (autosit aires, Geoffroy St. 
Hilaire) ; in the other, only one individual is especially deve- 
loped, the second being more or less atrophied, and forming, 
in a manner, a parasitic appendage to the first, double mon- 
sters by implantation, (per implant ationem — parasitaires, 
Geoffroy St. Hilaire.) 

A. DOUBLE MONSTERS BY COALITION. 

These double monsters may be separated into a great number of 
forms, of which we must here give only a brief sketch, without entering 
deeply into their anatomy. They form a connected series from a 
single individual with a few doubled parts, to two bodies almost com- 
pletely separated, and only attached at a very circumscribed spot. 

1. The duplication may be so inconsiderable, that exter- 
nally it can be scarcely or not at all perceived, while internal 



512 



MALFORMATIONS. 



parts, viscera, or the upper portion of the vertebral eolumn, 
with a corresponding part of the brain and skull, are 
doubled. 

All the forms of this duplication are very rare, and have 
hitherto been observed only in animals. The forms hitherto 
noticed are : 

a. Partial duplication of the vertex (dicoryphus* Bar- 
kow — dicranus, Gurlt). The cranium is doubled, the face 
not so, or only partially. The upper end of the vertebral 
column is also doubled, but there are present only two rows of 
ribs. Sometimes the superior extremities are also doubled. 
The brain and upper part of the spinal cord are more or less 
doubled. 

Heusner, descript. monstror. avium, &c. Diss. Berol. 1824; Gurlt, 
op, cit. p. 256. 

b. Partial duplication of the face (monocranus, Gurlt). 
The face may be partially doubled, the eyes, nose, tongue, 
and the cerebrum being especially implicated in the duplica- 
tion ; the cranium being single. 

Gurlt, vol. ii. p. 216, &c. 

2. The duplication may affect the upper half of the body. 
This may be more or less doubled, while the lower half of the 
body is single. The cases which belong to this class form a 
perfect transition-series from the simple cranial fissure to two 
almost completely separated bodies. The following are the 
principal forms : 

a. Duplication of the face (diprosopus, Barkow and 
Gurlt). The face is more or less doubled; the separation of 
the two faces commences anteriorly, and either does not 
extend at all, or only partially upon the skull. 

For the literature of this class see Barkow, vol. n. p. 36 ; and Otto, 
op. cit. p. 223, 225, &c. Geoffroy St. Hilaire,f divides this group into 

* Kopv(f>ri, the top of the head, 
t Vol. in. p. 195, &c. 



DOUBLE MONSTERS. 



513 



two genera: 1. Iniody?nus* (diprosopus sejunctus, Gurlt), which forms the 
higher grade. The two heads are united at the occiput, and consequently- 
all the cranial bones as far as the os occipitis are doubled ; also the organs 
of sense and the cerebrum; 2. Opodymus\ (dipros. dlstans, Gurlt), 
in which the face only as far as the zygoma is doubled, the skull is 
simple ; the cerebrum, however, being commonly doubled. 

b. Duplication of the whole head (dicephalus, Barkow 
and Gurlt). The whole head is doubled, and the upper part 
of the vertebral column is double. On the contrary, the 
thorax and abdomen are, at least externally, single. 

For the literature, see Barkow, vol. n. p. 37, &c. ; and Otto, p. 221, 
plate xxiv. figs. 2 and 3. Geoffroy St. HilaireJ distinguishes the follow- 
ing forms : 1 . Atlodymus, in which the two heads are seated upon one 
neck, and the duplication descends as far as the atlas. 2. Derodymus,^ 
in which the duplication extends to the neck ; the thorax, externally 
simple, presenting one sternum and a double vertebral column. 

c. The head, neck, and upper extremities may be doubled, 
while the chest and abdomen are single, or at least fused into 
one another, in the two bodies. Thoracico-abdominal du- 
plication, (didymus symphyothoraco gastrins, Barkow — 
thoraco-gastrodidymus, Gurlt) . 

Barkow, vol. n. p. 39, and vol. i. pi. m. fig. 1. Geoffroy St. Hilaire|| 
names this form Xyphodymus .*[[ In this division we must place the twin 
monster known under the name of Rita Cristina, who was born on the 
12th of March, 1829, at Possari (in Sardinia), and was brought alive 
to Paris, but died there in the November of the same year, after it had 
been subjected to some interesting physiological experiments. Other 
cases are given in Otto, p. 217, &c, and W. Griiber, Anatomie eines 
Monstrum bicorporium. Prag. 1844, with six plates. 

d. The duplication may extend to the thorax, while the 
abdomina coalesce, (didymus symphyogastrius, Barkow — - 

* iviovy the nape of the neck, 
f the face. 
+ Vol. in. p. 191. 
§ Uprj ,the neck. 

\\ Plate xv. fig. 1, and vol. in. p. 161, &c. 
^[ From the coalescence of the ensiform cartilages. 
VOL. L L L 



514 



MALFORMATIONS. 



g astro didymus, Gurlt). The lower extremities may in this 
case be single or doubled. 

Barkow, vol. n. p. 39. Geoffroy St. Hilaire* names this from Psody- 
mus.f A case recently described in Froriep's N. Notiz. vol. v. p. 152, 
of a double monster, born at Stammsried (Bavaria), in January, 1838, 
should probably be placed in this division. 

e. The duplication may extend as far as the centre of the 
abdomen, while the lower halves of the body, from the 
umbilicus downwards, coalesce, (didymus symphyohypogas- 
trius, Barkow — hypogastrodidymus, Gurlt). The lower 
extremities are likewise sometimes doubled. 

Barkow, vol. n. p. 40. Geoffroy St. Hilaire.J names this form 
Ischiopages j while Dubreuil assigns to it the term Ischiadelphus. The 
following recent cases have been recorded : J. A. Pereira, in Edin. 
Med. and Surg. Journ. 1844, vol. lxi. p. 58; Montgomery, in 
Todd's Cyclopaedia of Anatomy and Physiology, " Abnormal Anatomy 
of the Foetus," p. 317. 

/. The duplication may be almost complete, and the two 
bodies amalgamated at only a circumscribed spot, at the 
perineum, the sacrum, or coccyx, (didymus symphyoperi- 
nceus, Barkow — pygodidymus, Gurlt). 

Barkow, vol. n. p. 40. Geoffroy St. Hilaire§ names this form Pygo- 
pages. The Hungarian sisters, Helen and Judith, who were born at 
Szony, in Hungary, in the year 1701, and after being exhibited for a 
long time throughout Europe, died in tbeir twenty- second year, afford a 
good illustration of this form. 

3. The duplication may extend to the inferior half of the 
body, while the superior half is more or less single. 

a. The duplication may be limited to the organs of gene- 
ration, and the urinary bladder, and consequently to the 
anterior part of the pelvic region (di<zdoeus,\\ Barkow). This 
form is rare, and hitherto has been observed only in animals. 
For the literature, see Barkow, vol. n. p. 40. 

* Vol. in. p. 157. 
f \poa, the loins. 

X Plate xx. fig. 1, and vol. in. p. 69, &c. 
§ Plate xiv. fig. 2, and vol. in. p. 50. 
|| aldoiov, the generative apparatus. 



DOUBLE MONSTERS. 



515 



b. The duplication may be confined to the posterior part 
of the lower end of the trunk, the coccygeal region (dipygus, 
Barkow). It is, however, questionable if this form actually 
occurs ; at present, no instance of it is known. 

c. The pelvis may be completely doubled, together with a por- 
tion of the abdomen, (dihypogastrius, Barkow). This group 
separates into different subdivisions, according as the duplica- 
tion extends, more or less, upon the upper part of the 
body. 

Cases are recorded by Barkow, vol. 2. p. 41, &c. ; and Otto, p. 179, 
pi. xxiv. fig. 1 . The forms into which this group has been subdivided, 
are as follows : 1 . The head always single, and only the lower (hinder) 
part of the body, as far as the umbilicus, doubled, (monocephalus s. di- 
pygus, Gurlt — thoradelphus, Geoffroy St. Hilaire) ; this has been hitherto 
observed only in animals. See Gurlt, op. cit. vol. n. p. 257, &c. ; 
Gurlt and Hertwig, Magazin f. ges. Thierheilkde, vol. n. p. 2 & 180 ; 
and Geoffroy St. Hilaire, vol. in. p. 146, &c. 2. The upper jaw double, 
but amalgamated, and only the doubled lower part of the body, from the 
umbilicus downwards, separated, {octopus, Gurlt). This is again sepa- 
rable into various sub-forms : a. There may be present two more or less 
perfect faces {octopus Janus, Gurlt), a group which Geoffroy St. Hilaire 
has again divided into two genera, Janiceps and Iniops • both occur in 
the human subject, b. There may be only one face, and opposite to it 
two ears united at the base, as the rudiment of a second, {octopus quadri- 
auritus, Gurlt — synotus, Geoffroy St. Hilaire, vol. in. p. 126) : this also 
is not unfrequent in the human subject. c. Only the posterior parts of 
the head, the occipital and sphenoid bones may be double, the rest simple, 
{octopus biauritus, Gurlt — deradelphus, Geoffroy St. Hilaire, vol. in. 
p. 142) : in man this is very rare, but not very unfrequent in animals. 

d. The duplication may be almost complete, and the two 
bodies connected at only a circumscribed spot on the head, 
{didymus symphyocephalus, Barkow). 

For cases, see Barkow, vol. n. p. 43 ; and Otto, p. 179. The forms 
belonging to this group have been further reduced to several sub- 
divisions : 1 . The two bodies may be attached at the occiput, didymus 
symphyopistocephalus, Barkow). 2. They may be connected at the 
vertex, {didymus symphyocoryphus, Barkow). These two forms are 
comprised by Geoffroy St. Hilaire in the genus Cephalopages* 



* PI. xix. fig. 1 & 2, and vol. in. p. 60, &c. 

L L 2 



516 



MALFORMATIONS. 



3. They may be attached at the forehead {didymus symphyometopus, 
Barkow — metopages, Geoffroy St. Hilaire, vol. in. p. 56). Cases 
belonging to this group are very rare in man. 

4. The duplication may simultaneously affect the upper 
and lower ends of the body, the two bodies being amalga 
mated in the middle. 

a. The duplication may affect, superiorly, the face, and 
inferiorly, the anterior pelvic region {diprosopus dicedceus, 
Barkow; tetrascelus in part, Gurlt). It does not occur in 
the human subject : cases which have occurred in animals 
have been collected by Barkow, vol. II. p. 43. 

b. The duplication may affect, superiorly, the face, and infe- , 
riorly, the lower part of the body {diprosopus dihypogastrius, 
Barkow ; tetrascelus in part, Gurlt) ; four lower extremities 
are here always present. 

Frequently observed in man. See Barkow, vol. n. p. 43. 

c. The duplication and separation may affect, superiorly, 
the vertex, and inferiorly, the parts from the umbilicus down- 
wards (dicoryphus dihypogastrius, Barkow — octopus synap- 
teocephalus, Gurlt). 

Barkow, vol. n. p. 44; vol. i. pi. n. fig. 1. Geoffroy St. Hilaire 
terms this form, hemipages (vol. in. p. 104). 

d. The head and neck superiorly, and the lower half of 
the body from the umbilicus downwards, may be doubled 
and separated ; the amalgamation taking place on the thorax 
and upper part of the abdomen, either on the anterior sur- 
faces of the bodies, or more laterally {thoracodidymus, Gurlt ; 
dicephalus dihypogastrius, and, as a higher degree, didymus 
symphyothora ccepigastrius, Barkow . 

Both, but especially Barkow's second form, are not unfrequent in the 
human subject. See cases in Barkow, vol. n. p. 44, &c. ; Cruveilhier, 
Anat. pathol. livr. xxv. pi. v. ; Otto, p. 170, &c. ; and in Geoffroy St. 
Hilaire, who separates these cases into two genera : 1 . Sternopages, with 
anterior amalgamation (vol. in. p. 93, &c.) 2. Ectopages, with lateral 
amalgamation (vol. in. p. 98, &c.) 

e. There may be almost complete duplication, with separa- 
tion of the two bodies, which are amalgamated only in the 



DOUBLE MONSTERS. 



517 



upper region of the abdomen (didymus symphyoepigastrius, 
Barkow) . 

Cases of this nature are rare; several are collected in Barkow, 
vol. ii. p. 45, and in Geoffroy St. Hilaire,* who names this form Xipho- 
pages. We must here include the celebrated case of the Siamese 
twins ; also a case described by Fanzago (Storia del mostro di due corpi, 
etc. Padova, 1803), with a beautiful illustration ; see also Otto, 
p. 169, &c. 

B. PARASITIC DOUBLE MONSTERS. MONSTERS BY IMPLANTATION. 

The amalgamated bodies are here not equally developed, one 
being more or less atrophied, and either apparent externally 
on the more perfect individual, or so concealed under the skin 
or inclosed within the cavities of the body, that it is not 
outwardly visible. 

The cases belonging to this division arise either like perfect 
double malformation, by splitting of one germ, of which, how- 
ever, half becomes atrophied, or, compared to the other, is 
backward in its development — -or two germs exist from the 
first (an ovum with two germinal vesicles, or two ova), which 
unite together, or of which the more developed one encloses 
within itself that which is less perfect. We may distinguish 
the following forms of these malformations : 

1. A perfect individual may bear on its head, not like the 
didymus symphyocephalus or cephalopages, a fully developed 
second individual, but only a head with traces of the rest of 
the body. It is very rare. 

Geoffroy St. Hilaire, who has collected several of these cases (vol. in. 
p. 239. &c, and pi. xx. fig. 3), names the form, epicoma. 

2. On the head of a more or less perfectly developed 
foetus, attached either to the palate or the lower jaw, there 
may be very imperfect rudiments of a second head. 

Geoffroy St. Hilaire arranges (vol. in. p. 250, &c.„ pi. xx. fig. 3,) 
these rare cases in three genera; 1 . Epignathus; where an accessory very de- 
fective, and, in all its parts, very malformed head is attached to the palate 

* Vol. in. p. 80, &c. 



518 



MALFORMATIONS. 



of the developed individual. (We should here probably place a case 
described by J. C. L. Haack, in his Diss, sistens. descr. anat. et del. 
foetus parasitici. Kiliae, 1826). 2. Hypognatus ; where a very defec- 
tive second head is situated nor the lower jaw of the developed indi- 
dual. 3. Augnathus ; where a very rudimentary head, which is almost 
limited to a lower jaw, is seated on the lower jaw of the developed indi- 
vidual. 

3. On a well developed, or more or less normal body, a 
second, smaller and more or less defective one may be situ- 
ated, which, after birth, does not increase in size. It is gene- 
rally attached to the thorax, or upper part of the abdomen 
(heterodidymus, Gurlt). 

Geoffroy St. Hilaire* places these cases in three subdivisions: 1. 
Heteropages ; where the undeveloped second individual possesses an 
evident head, and at least rudiments of lower extremities, and is, there- 
fore, almost complete. 2. Heteradelphus ; where the parasite consists of 
only a lower half of a body — its head and sometimes also its thorax 
being wanting. 3. Heterodymus ; where the parasite consists of only 
an imperfect upper half of a body (head, neck, and thorax) ; the lower 
half being wanting. Additional cases are described by J. Wirtensohn, 
Duor. monstror. dupl. human, descript. Berol. 1825 ; and by J. Faese- 
beck, in Midler's Archiv. 1842, p. 61. 

4. In a more or less perfectly developed individual there 
may be concealed under the skin, in a tumour or in a cavity 
of the body — commonly in the abdomen — parts of a second 
individual, which, however, are not amalgamated with the 
corresponding parts of the first, but are more or less isolated. 
This condition has received the name of foetus in foetu. It 
is most probably caused by the inclusion of one germ by 
another ; not, as Meckel believed, by generative-like multipli- 
cation. 

With this condition we must not confound extra-uterine pregnancy 
with ossification of the child (lithopadion) nor the bony particles formerly 
mentioned, which, with teeth and hair, sometimes occur in encysted 
tumours, and by some are maintained to be parts of a foetus. Cases of 
this nature are given in Meckel, vol. n. p. 69, &c. ; Geoffroy St. Hilaire, 
vol. in. p. 291, &c, who names these malformations endocymiens ; also 



* PI. xviii. and vol. in. p, 211, &c. 



TRIPLET MONSTERS. 



519 



in Fattori, whose work, de* feti che racchiudono feti detti volgarmente 
gravidic Pavia, 1815, besides enumerating the earlier literature, contains 
the description of an interesting case, with exceedingly beautiful illustra- 
tions. More recent cases may be found in Schaumann, diss, sistens 
cas. rarior. foetus in foetu. Berol. 1839 ; and Schonfeld, Annales de 
Gynecolog. et Pediatrique. Septbre. 1841 ; or Froriep's N. Notizen, 
vol. xx. 1841. p. 137. 

TRIPLET MONSTERS (MONSTRA TRIPLICA S. TRIGEMINA). 

Some portions of the body are here not merely doubled, as 
in the case of twin monsters, but tripled. Triplet monsters 
are, indeed, very rare ; but latterly, even in man, their exist- 
ence has been positively shown. 

See the cases in Geoffroy St. Hilaire, vol. in. p. 327, where one of 
especial interest is communicated — a child with three heads, observed 
in 1832, by Drs. Reina and Galvagni, in Catania. 

SIXTH CLASS. 

MALFORMATIONS IN WHICH ONE OR MANY PARTS HAVE AN ABNORMAL 
SITUATION (SITUS MUTATUS), 

The malformations belonging to this class may be brought 
into the following subdivisions : 

1. Congenital abnormalities in the situation of the viscera. 
The highest degree is seen in the complete reversing of all 
internal organs, in which the heart and spleen lie upon the 
right, the liver and caecum upon the left side, without the 
viability being in any way impaired. Of this anomaly, which 
has its origin in an abnormal development, the causes are 
quite unknown. 

For cases, see Meckel, vol. n. p. 183, &c. ; and Geoffroy St. Hilaire, 
vol. ii. p. 6, &c. More recent cases are given in Herholdt, Beschrei- 
bung sechs menschlicher Missgeburten. Copenhagen, 1830. Case i. 
and p. 65 ; and Valentin's Repertorium, 1837, p. 173. 

2. Anomalies in the course of individual vessels 
(arteries, veins, and lymphatics). They are very nume- 
rous and diversified. Their mode of origin cannot be 



520 



MALFORMATIONS. 



explained without entering deeply into the history of deve- 
lopment.* 

3. Changes in the arrangement of the bones, curvature of 
the vertebral column, club-foot, club-hand, &c, are for the 
most part the consequences of abnormal contractions of the 
muscles during fcetal life. 

For cases of this nature see Cruveilhier, Anat. pathol. livr. n. pi. n., 
in., iv. ; and Otto, pp. 281, 284, 317, 322. 

SEVENTH CLASS. 

MALFORMATIONS OF THE GENERATIVE ORGANS HERMAPHRODITISM. 

In this class we must place the cases where, in consequence 
of abnormal development, the generative organs of one sex 
approximate to those of the other, or where on one and the 
same individual both male and female generative organs occur 
— in short, all malformations affecting the generative appa- 
ratus, whereby the sex is made at all doubtful. 

For the general literature, see Meckel, vol. n. Part 1, p. 196, et 
seq. ; Geoffroy St. Hilaire, vol. n. p. 30 et seq. ; Simpson's article, Her- 
maphroditism in Todd's Cyclopaedia of Anatomy and Physiology, 
p. 684 ; J. F. Ackermann, Infantis androgyni historia. Jena?, 1805 ; and 
G. Steglehner, de hermaphroditorum natura, 1817. 

This class is usually arranged in two divisions : 

1. False hermaphroditism, where the occurrence of double 
sexual organs is only apparent. 

2. True hermaphroditism, where male and female organs 
of generation actually occur in the same individual. 

1. FALSE HERMAPHRODITISM. 

All cases belonging to this division, are characterized by the 
sexual organs of an individual, or at least the external parts 
of generation approximating, in consequence of malformation, 
more or less closely to those of the opposite sex, so as to 
render the sex doubtful. 



* See Bischoff, op. cit. p. 918. 



HERMAPHRODITISM. 



521 



These malformations occur in females and in males. 

a. IN FEMALES. 

In this case the resemblance to the male sex may be oc- 
casioned : 

1 . By disproportionate size of the clitoris, so that it may 
be mistaken for a penis. This mistaking of the clitoris for a 
penis may, in infants, occur the more easily, since in the 
foetus, almost until birth, the clitoris is not much smaller than 
the penis. In many cases, again, the clitoris grows remark- 
ably after birth, and often attains a very considerable size 
(from two to five, or even seven inches in length, with propor- 
tionate thickness). In addition to this the clitoris is some- 
times furnished at its anterior termination with an orifice, 
which resembles that of the urethra of the male, or has, infe- 
riorly, a channel which corresponds to the male urethra; 
sometimes also the prepuce is much developed. Now if, 
at the same time, as is frequently the case, there is constric- 
tion of the vagina, considerable development of the hymen, 
tumefaction of the labia pudendi, approximation of the total 
habitus to the male sex by deep voice, traces of beard, and 
slightly developed mammae ; such individuals may be easily 
mistaken for men. 

2. The apparent approximation of the female generative 
organs to those of the male, may be caused by prolapse of the 
uterus. However improbable this sounds, yet cases are 
known where by reason of such a prolapse the sex became 
in the highest degree doubtful ; indeed, when females have 
even married as men. 

For cases see Meckel, vol. n. p. 200 et seq. ; Nega, de congenitis 
genital, fcemineor. deformitat. Vratisl. 1837, (only a small portion of it, 
however, refers to this subject) ; Becker, de hermaphroditismo, Jense, 
1842 ; and Oesterr. mediz. Wochenschr. 1843, p. 701. 

b. IN MALES. 

A resemblance to the female sex is produced by several 
malformations. 



522 



MALFORMATIONS. 



1. By fissure and eversion of the urinary bladder with 
prolapse of its posterior wall, a condition already treated of 
under the head of fissures. This fissured bladder, although 
situated above the pubis, has been repeatedly mistaken for 
the vagina, especially in the cases where the intestinal canal 
has opened into it (cloacal structure), and where at the same 
time the male generative organs have been much atrophied. 
The latter is, indeed, usually the case in this condition ; that 
is to say, the penis is nearly always imperfectly developed and 
cleft upon its upper side (epispadias). 

2. In rare cases, the approximation of the male genitals 
to the female habitus, is produced by the penis of the 
infant being attached to the scrotum by false ligaments and 
adhesions ; it is thus drawn downwards and appears to have 
vanished ; the deception is further favoured when the testicles 
do not descend. 

3. Most frequently false hermaphroditism in the male sex, 
arises from the urethra being fissured beneath and atrophied, 
(hypospadias) while, at the same time, also, the scrotum and 
even the perineum are cleft, so that the fissure resembles the 
female vulva ; the resemblance being increased by the circum- 
stance that like the latter, it is lined with a soft, red, mucous 
membrane. 

Generally, also, in such cases the testicles have not de- 
scended (cryptorchismus), which adds to the deception, 
so that such individuals have been frequently taken for girls 
until the period of puberty, when they have suddenly changed 
into men. 

For cases see Meckel, vol. n. p. 207 ; Th. Brand, the case of a boy 
who had been mistaken for a girl, London, 1787, with illustrations ; 
H. A. Wrisberg, comment, de singul. genit. deform, in puero herma- 
phrodit. ment. Gcetting, 1796 ; F. H. Martens, Beschreib. und Abbild. 
einen sonderbaren Missgestaltung der Mannl. Geschlechtstheile, Leipz. 
1802 ; Rapp in Casper's Wochensch. 1843, No. 32, p. 522 ; and Otto, 
op. cit. p. 205. 

On cloacal structure generally, see Wedel, Diss, monstri human rar. 
descr. cont. Jense, 1830, c. tab. ; Ulrich, Diss. Marburg. 1833, c. tab. ; 
Otto, p. 308, et seq. 



HERMAPHRODITISM. 



523 



The origin of these malformations is explained by the history of the 
development of the genital organs, and chiefly depends on arrest of 
structure. At first there exists in both sexes a common orifice for the 
urinary apparatus, generative organs, and intestinal canal : an arrest 
of development at this stage causes cloacal malformation. At an after 
period the termination of the rectum is separated from the urino-gene- 
rative aperture ; in the male sex the latter becomes closed as far as the 
orifice of the urethra ; in the female, on the contrary, it remains divided. 
Now, if an arrest of formation interferes anterior to the period of this 
change, the external genital organs of a male foetus bear a close resem- 
blance to those of a female ; the penis remains small, undeveloped, 
and is not perforated by the urethra, and consequently is very similar 
to the clitoris. 

II. TRUE HERMAPHRODITISM. 

This comprises the cases where male and female organs of 
generation actually occur together in one individual. In the 
human subject few cases are at present known which can 
be regarded as pertaining to true hermaphroditism, and even 
some of these are in the highest degree questionable. It is, 
for instance, very difficult, sometimes, indeed, almost impos- 
sible to distinguish with certainty, the different corresponding 
generative organs of the two sexes from each other, as testicle 
and ovary, or vas deferens and fallopian tube, when they 
are malformed or atrophied. Moreover, all these individuals 
are incapable of propagation, and consequently a practical 
determination of their true sex is impossible. 

For these reasons the occurrence of true hermaphroditism 
in the human subject is totally denied by some, and all cases 
of this nature, referred, as merely apparent, to false herma- 
phroditism. # I shall, therefore, content myself with giving a 
brief sketch of the forms which have been hitherto observed of 
true hermaphroditism, without desiring to be held responsi- 
ble for the accuracy of the individual observations. 

The cases which have been observed may be brought into 
the following groups : 

1 . The internal sexual organs may differ on the two sides, 



* See Bischoff, op. cit. vol. i. p. 919. 



524 



MALFORMATIONS. 



being on the one side male, and on the other female (herma- 
phrodismus lateralis). On one side of the body is an 
ovary, on the other a testicle. 

For cases see Meckel, vol. n. Part 1, p. 213; Rudolphi, Abhandlun- 
gen der Berlinen Akademie der Wissenschaften, 1825; J. C. Meyer, 
Caspar's Wochenschr. 1835, No. 7 ; Berthold, iiber seitliche Zwitter- 
bildung, Gottingen, 1844, (reprinted from vol. n. of Abhandlungen 
der Konigl. Gesellscb. der Wissenschaften zu Gottingen). 

2. The external genital organs may differ from the inter- 
nal ; the external being female, the internal male ; and less 
frequently the converse. Most of these cases are probably 
founded on deception, and belong to false hermaphrodi- 
tism. 

3. Hermaphrodites with increased number of parts ; cer- 
tain male sexual organs are present with a perfect female 
system, and the converse. 

A few cases are given in Meckel, vol. n. p. 215, et seq. All these 
and some other more recent cases are, however, in the highest degree 
questionable, and are probably founded upon a false interpretation of the 
supernumerary parts. 

Additional matter on congenital malformations of the 
sexual organs will be found in the special part. 



As an appendix we may add certain pathological changes 
of the foetus, which are not commonly classed with con- 
genital malformations — as tumours and other morbid pro- 
ducts ; also the alterations which the foetus undergoes when 
retained in the abdominal cavity in extra-uterine gestation 
(lithopadion) ; and various pathological changes of the placenta 
and membranes of the ovum. 

Most of these pathological changes are as yet very imperfectly under- 
stood, and, as in the case of the malformations, a profound considera- 
tion of them is impossible without entering deeply into the history of 
development. I am, therefore, content in this place, to refer to a few 
works which contain more special statements respecting certain of these 
morbid alterations. 



DISEASES OF THE FCETUS AND PLACENTA. 325 



On diseases of the foetus, consult J. Gratzer, die Krankheiten des 
Foetus, Breslau, 1837 ; Cruveilhier, Anat. pathol. liv. 15, PI. u. ; Otto, 
op. cit. p. 317, et seq. 

On Lithopaedia, see Cruveilhier, op. cit. liv. 15, PI. vi. 

On pathological changes of the placenta, and membranes of the 
ovum, see Ruysch, Observat. cent. Obs. 58. Molarumorigo et natura ; 
Meckel, vol. i. p. 82 et seq. ; Cruveilhier, op. cit. liv. 1, PL i. and n. 
liv. 6, PL vi. liv. 16, PL i. ; Valentin, on the minute structure of a 
disorganization of the human ovum which is of frequent occurrence, and 
leads to abortion, in his Repertorium, vol. i. 1836, p. 126, et seq. ; 
W. Vrolik, Handboek, &c, and Hannoversche Annalen, 1843, p. 723, 
et seq. ; and Pappenheim, Neue Zeitschrift fur Geburtskunde v. Busch, 
d'Outrepont undRitgen, 1841, p. 300. 



526 



POST MORTEM CHANGES. 



CHAPTER X. 

CHANGES OCCURRING IN THE BODY AFTER DEATH- 
POST MORTEM CHANGES. 

It is only in occasional cases that we have the oppor- 
tunity in the human subject of examining diseased parts 
of the body whilst perfectly fresh, such as extirpated tumours 
or amputated extremities. In general, a shorter or longer 
period elapses between death and the examination, and during 
this interval, through the agency of putrefaction, changes 
frequently occur in the elements of the body which may be 
easily confounded with such alterations as, during life, were 
produced by disease. The study of cadaveric changes is, 
therefore, necessary, lest false conclusions should be drawn 
from the state of the corpse, with respect to existing patho- 
logical alterations. 

It has, however, still another object which is of more espe- 
cial importance in relation to medical jurisprudence, and 
consists in the reply to certain questions which are frequently 
put to the medical jurist. Such queries are chiefly as follows : 

1 . Has a person died a natural or violent death ? 

2. How long a period has elapsed since his death ? 

3. In what condition was the corpse found ? 

The cadaveric changes interest us here chiefly with refe- 
rence to the first question. They are commonly placed in 
direct opposition to those which take place during life, and 
the two are held to be essentially different, since, as it is 
reasoned, the latter have arisen under the influence of the 
vital force, while the former, on the contrary, have resulted 
in accordance with totally different laws, namely, the strictly 



POST MORTEM CHANGES. 



527 



physical and chemical laws, which govern inorganic nature. 
This is an erroneous or at least illogical view, founded upon 
the fact that a false idea is commonly attached to the term 
' vital force.' This is not a simple power sui generis, it is 
rather the common result of all the different and innumerable 
forces operating within the human body : of these, again, the 
greatest number (all, with the exception of the psychical) act 
according to physico-chemical principles. Many of these 
forces certainly cease at the moment of death, some before, 
others shortly after — as, for instance, all operations which 
depend upon the mind, the united activity of the nervous 
system, with every voluntary or involuntary movement de- 
pendant on it, the circulation, &c. Others, on the contrary, 
continue in operation after death, and upon these, which 
certainly are greatly modified by the abstraction of the above 
mentioned forces, depends the occurrence of the cadaveric 
changes, and not upon any new agencies that may come into 
operation only after death. These phenomena are those of 
putrefaction and decomposition : even during life perfectly 
analogous processes are taking place at every instant and in 
every part of the system, but their products are being con- 
tinuously carried away from their original place by the circu- 
lation, and removed from the body by means of the secretions. 
But as the mechanism of the circulation and of the secretions 
ceases with life, these products of decomposition are then no 
longer removed ; they accumulate, and perhaps experience che- 
mical modifications which could not occur during life; and pecu- 
liar results may be manifested, which on a superficial considera- 
tion of their mode of origin seem to be very different from 
the changes occurring during life. Such is, however, in reality, 
not the case, since, for example, in gangrene, changes some- 
times occur during life, perfectly analogous to the phenomena 
of putrefaction, as seen after death. 

The cadaveric changes no less than the metamorphoses 
during life, are the products of a very great number of agents, 
and it is, therefore, difficult, and, indeed, impossible to lay 
down general laws for their establishment. We may consider 



528 



POST MORTEM CHANGES. 



the following as amongst the most important agencies which 
exercise an influence upon cadaveric changes. 

1 . The state of the constituents of the body at the moment 
of death. The condition of the blood is here of great impor- 
tance, since this fluid is not only generally the first of all parts 
of the corpse to suffer further changes and decomposition, but 
also, by means of these, gives rise to metamorphoses in many 
other elements of the body. We must here take into consi- 
deration the quantity and quality of this fluid, and its distri- 
bution, also the condition of the other parts of the body, the 
amount of fat they contain, and other characters, as, for in- 
stance, their vascularity. 

2. The state of the temperature, the degree of warmth of 
the body at the moment of death, the rapidity or slowness 
with which this warmth escapes, the humidity of the atmos- 
phere, and the other ordinary relations which either retard or 
accelerate the course of the chemical changes previously going 
on in the body. To these may be added, as important in 
many respects, the situation of the body after death ; including 
the circumstances whether the body lay exposed to the atmos- 
phere, whether it had been buried, or had been lying in water. 

3. In the critical examination of the cadaveric changes, the 
time which has elapsed since death, is a point of very great 
importance. 

Upon these influences depend partly the quality of the 
changes, and partly their quicker or slower occurrence, and 
their greater or less intensity. At present, unfortunately, we 
are unable accurately to establish the influence of the indivi- 
dual agents, and thus, conversely, from a change in a corpse, 
to conclude with certainty upon its cause. 

Since, with a view to pathological anatomy, it is our espe- 
cial object to draw a conclusion regarding the state of the 
body at the moment of death, from the changes presented 
by the corpse, it is advisable always to make the exami- 
nation with as little delay as possible ; examinations after the 
lapse of a considerable period have little or no value for pa- 
thological anatomy. It often happens, however, that the 



POST MORTEM CHANGES. 



529 



dissection cannot be immediately made, and it becomes, 
therefore, necessary to be acquainted with those cadaveric 
changes which, under ordinary relations, generally occur 
within a day or two after death, in order to conclude from 
them whether the alterations which present themselves are 
really of a morbid character. 

The most important cadaveric changes are those which 
take place in the Mood and vascular system. They are inti- 
timately allied to the formerly detailed modifications of the 
blood, and have been in part already described (see pp. 59 — 
98, 391, and 403). 

The blood coagulates first in the larger vessels, namely, 
in the heart and the large venous trunks, and to a less degree 
in the arteries, which are often contracted after death, having 
expelled the greater part of their contents. When they 
afterwards again relax, the blood has coagulated and does not 
return into them. The blood does not, however, always coa- 
gulate : in many cases, where its fibrin is modified and has 
lost its characteristic coagulability, it remains more or less 
fluid. 

Considerable alterations commonly ensue in the distribution 
of the blood. 

Capillary hyperemia may diminish or totally disappear, 
since, by the contraction of the arteries and capillaries oc- 
curing after death, the blood is more or less expelled from 
them. Hence, capillary hyperemia which existed during life 
cannot always be discovered in the dead body, unless the exa- 
mination has been made at a very early period. This morbid 
change is most frequently and beautifully observed in hot 
climates, where the examination is generally made a few 
hours after death. 

On the other hand, venous hyperaemia may increase or ori- 
ginate after death, since the blood contained during life in 
the arteries and capillaries leaves them with the post mortem 
contraction of these vessels, and passes into the veins fur- 
nished with more yielding walls. 

VOL. I. MM 



530 



POST MORTEM CHANGES. 



To cases of hyperemia which arise after death (cadaveric 
hyperemia, hypostases) also belong those compounded of 
capillary and venous hyperemia, which, after the cessation of 
the circulation, arise according to the laws of gravity ; since 
the blood of a part whose capillaries are connected, gravitates 
to the lowest portions of it, and there gorges the capillaries 
and veins. Such a cadaveric hyperemia, like venous hypera- 
emia occurring during life, may when of long continuance 
result in serous dropsy. 

Cadaveric hyperemia arises with the greatest facility in 
organs whose capillary vessels are very large, and therefore 
present the most favourable conditions for a subsidence of 
the blood within them according to the laws of gravi- 
tation and capillarity. It must be also presumed that the 
capillaries are open, and connected at very many points. 
Consequently this species of hyperemia occur by far most 
frequently in the lungs, whose capillaries not only anastomose 
abundantly together, but are also very large ; cadaveric hyper- 
emia combined with more or less serous dropsy (oedema) is 
found in the majority of subjects, either in the posterior or 
lower part of the lungs, according to the position of the body. 
Cadaveric hyperemia is found in a less degree in the skin, 
(some of what are termed death spots belong to this class), 
and in the intestinal canal, where the capillary vessels are con- 
nected throughout the whole organ, although not with such 
numerous and extensive anastomoses as in the lungs. Between 
parts which are not directly connected by capillary vessels, but 
only by means of larger vascular trunks, as between the heart 
and the lungs, the lungs and costal pleura, &c, cadaveric 
hyperemia never occurs. 

In cadaveric hyperemia, it is moreover presupposed that the 
blood is fluid : the more liquid it is, the more easily does it 
take place. The intensity depends on the quantity of blood 
which the organ contains at the moment of death. It is, 
accordingly, more considerable in a hyperemic, slighter or 
quite absent in an anaemic part. It is possible that such cada- 
veric hyperemia may commence in the last moments of life, 



POST MORTEM CHANGES. 



531 



when the force of the circulation has become generally and 
locally so weakened that it can no longer counteract the 
influence of gravitation upon the blood : this especially applies 
to the lungs. 

To these changes in the distribution of the blood are allied 
various modifications of the blood itself, which are at present 
very little understood, with respect to their chemical nature. 
The most important of them may at present be characterised 
as a solution of the blood-^corpuscles, (that is of their colour- 
ing matter), which is observed in rare cases during life (see 
p. 97). In consequence of this, a red plasma is conveyed 
into the tissues whence is frequently produced the semblance 
of a capillary hypersemia (constituting another division of the 
death spots). The precise chemical changes of the blood 
which effect the solution are unknown, for although, as 
commonly happens, they are properly referred to decomposi- 
tion or putrefaction, yet this is in reality no explanation of 
the change. 

A true explanation would consist in a demonstration of the 
special chemical cause which produces the solution of the 
blood-corpuscles. This proof is still wanting, although in 
many cases the solution can be referred with great probability 
to the generation of carbonate of ammonia in the blood. The 
diagnosis of this state, as was formerly mentioned, rests on 
microscopic examination, which shows that the blood-corpus- 
cles have disappeared and their pigment been dissolved in the 
liquor sanguinis. 

As a second change of the blood, which is accustomed to 
take place in the dead body, although not until a later period, 
we must mention a re-solution of the blood which had coa- 
gulated after death: this, likewise, is probably due to the 
formation of carbonate of ammonia. 

To these may be added other changes (commonly called 
putrefactive phenomena) that usually commence in the blood, 
but are not confined to it, extending to other parts of the 
body, Such are various phenomena which, for the most 

M M 2 



532 



POST MORTEM CHANGES. 



part, have been already described in their appropriate sections, 
as evolution of gas and softening in different parts of the 
body, increase of volume of certain parts from gaseous dis- 
tension or infiltration of fluids, changes of colour indepen- 
dent of the above mentioned imbibition of haematin, namely 
pseudo-melanosis from decomposition of hsematin or the 
formation of sulphuret of iron, and green colorations, de- 
pending partly on imbibition of the colouring matter of the 
bile, and partly upon other unknown causes active in pu- 
trefaction. 

We must also here include the rigor mortis, or death- 
stiffening, which as the animal heat disappears, invades all 
contractile parts of the body — the muscles of voluntary and 
involuntary motion, fibrous tissues, &c. 

Parasitic plants and animals may also appear in the body 
after death, and are therefore so far to be noticed amongst 
cadaveric changes. 

From these statements it will be perceived how cadaveric 
changes may partly efface certain pathological alterations, 
and partly simulate them ; and consequently how important it 
is to be upon our guard against being deceived by them in 
the examination of the dead body. 

The cadaveric changes above described are the most im- 
portant of those which usually ensue during the first days 
after death. At a later period they are so considerable that 
the examination of the body is of no use in leading to a cor- 
rect recognition of pathological relations. The alterations 
which then occur, fall within the province of forensic medicine, 
and do not require any further explanation in this place. 

Some of the changes subsequently occurring, and which are of the 
greatest importance to forensic medicine, are fully discussed in the fol- 
lowing works : 

A. Devergie, medicine legale, and 

Orfila, traits sur les exhumations juridiques, to which I therefore 
refer. 



EXPLANATION OP THE PLATES. 



PLATE I. 

Contains illustrations of the different forms of cells occurring in 
the development of morbid epigeneses. 

Fig. 1. Is an ideal figure, illustrating the formation of a cell. In an 
amorphous substance (A A), the cytoblastema, lie three ideal cells, 
(B, C, D). The cell B appears oval; we distinguish in it a clear 
ring with a very distinct external and internal contour (x x), the 
cell-wall ; in the interior of the ring, an elliptical body (z) the 
nucleus or cyteblast ; and in it, two round dark corpuscles, the 
nucleoli. The space between the cell- wall and nucleus, the cavity 
of the cell, is filled with a fluid which escapes observation. 
The cell C is round ; here we observe an evidently distinct cell- wall, 
and an equally clear nucleus, with a single nucleolus in the centre ; the 
cavity is filled with dark granular matter. 

The cell D is likewise round, and exhibits a clear cell- wall, with a 
more evident internal and external contour. The nucleus does not 
lie in the centre of the cavity, but on its circumference, on the inner 
surface of the wall, and contains distinct nucleoli. The contents 
of this cell are granular in the vicinity of the nucleus, but fluid and 
invisible in the remainder of the cavity. 

Fig. 2. A. Is a cell from encephaloid, occurring in the knee-joint. 

B. Cells from pulmonary tubercles. Magnified 220 diameters. 
These cells are perfectly round, and we distinguish in them a 
tolerably thick transparent cell- wall, and dark granular contents. 
Here there can be no doubt as to the granular mass being actually in 
the interior of the cell, in the cell- cavity. At A there are also sepa- 
rate granules on the outer circumference of the cell- wall ; we see an 
undoubted pale nucleus with a nucleolus in the upper part of the 
cell-cavity ; in the cells B, the nuclei are not evident. 
Fig. 3. A. Are cells from the substance of pulmonary tubercle. 

B. Cells from the expectoration in pneumonia. Magnified 
220 diameters. 

These cells also appear granular, but we cannot decide with 
certainty whether the granular mass is in the interior of the cells, 
or whether it is situated on the exterior of the cell-wall. 
Fig. 4. Very pale non- nucleated cells (?) of an indefinitely oval form, 

from the contents of an encysted tumour. Magnified 220 

diameters. 



534 



EXPLANATION OF THE PLATES. 



Fig. 5. Cells with two nuclei, magnified 220 diameters, a. an oval 
cell from encephaloid affecting the knee-joint, b. a cell of irregular 
form from the liver (normal hepatic cell). 

Fig. 6. Cells containing many nuclei in their interior, from encepha- 
loid of the uterus. Magnified 220 diameters. 

Fig. 7. Large cells, in the interior of which there are smaller but 
perfect cells, (parent- cells with young cells,) from encephaloid of 
the bladder. Magnified 220 diameters. The cell A is complete ; 
B is the mere outline. 

Fig. 8. Cells containing yellow pigment (bile-pigment) from a 
diseased liver. Magnified 220 diameters. 

Fig. 9. Cells containing fat, from a fatty liver. Magnified 220 dia- 
meters. The fat-globules are very small in some ; in others they 
are larger and more distinct. 

Fig. 10. Cells containing black granular pigment from a lung com- 
pressed by empyema. Magnified 220 diameters. 

Fig. 11. Nucleated cells of very irregular form, from encephaloid of 
the stomach. Magnified 220 diameters. 

Fig. 12. Very elongated caudate nucleated cells. A, from a semi- 
organized exudation in the pulmonary pleura. B, from a newly 
formed sac, attached to the pulmonary and costal pleura, and con- 
taining a fluid of the same chemical composition as the serum of 
the blood. Magnified 220 diameters. 

In A and B the cell becomes gradually thinner and is finally 
elongated to a mere thread ; in B b, several such cells are united by 
their pointed extremities, and form a single varicose fibre. 
Fig. 13 and 14 demonstrate the origin and growth of cells in morbid 

products. Magnified 220 diameters. 
Fig. 13. Represents different parts of a tuberculous lung. At A we 
perceive the earliest perceptible stage of the disease ; many nuclei 
with or without nucleoli, in an amorphous cystoblastema. At B 
the cytoblastema is consumed, and we can only trace a mass of 
nuclei lying closely on one another. C represents nuclei around 
which a pale soft cell-wall is already formed. At D there are 
wholly developed cells. 
Fig. 14. Shows portions of a scirrhous testicle. At A we see a 
firm amorphous cytoblastema, in which distinct cells are being 
developed ; most of these exhibit an evident nucleus, while in 
some, the cell- wall merging into the cytoblastema, appears like a 
broad, clear ring. At B the cells are more evident, and more dis- 
tinctly separated from the cytoblastema. 



EXPLANATION OF THE PLATES. 



535 



PLATE II. 

INFLAMMATION, FIBRINOUS EXUDATION, AND THEIR DEVELOPMENT. 

Fig. 1. A piece of inflamed mucous membrane from the trachea of a 
young man who died from febris mucosa. The respiratory mucous 
membrane was especially attacked by the disease ; during life there 
had been difficult respiration, rhonchus sibilans in both lungs, and 
moderate expectoration, containing pus and mucus streaked with 
blood. 

On dissection, the mucous membrane of the trachea was found to 
be much reddened; the colour passing into a violet tint, but on 
exposure to air soon changing to a clear red. (A) exhibits a piece of 
this mucous membrane, as it appeared to the naked eye. 

Seen under a power of 220 diameters, normal ciliated epithelium 
was visible, the separate cells being for the most part rubbed off, so 
that the surface of the mucous membrane appeared free. (B) shews 
the free surface of the mucous membrane after the epithelium had 
been removed. Magnified 220 diameters. We saw a very thick 
vascular network, the vessels having a larger diameter than usual, and 
being entirely filled with stagnant blood, which was, however, still 
fluid, and flowed from them on pressure. On examining this 
expelled blood, the blood- corpuscles were seen to be little changed in 
their form ; they were more globular than usual, and had lost the cup- 
like depression in their centre (Fig. 1, **). The vascular reticulations 
were so close, that they in some places entirely covered the paren- 
chyma of the mucous membrane ; and where the latter is visible, it 
was colourless, or of a faintly brown tint, and had the usual appear- 
ance of normal mucous membrane. 

Fig. 2 — 5 illustrate different stages of development of effused and 

coagulated fibrin. Magnified 220 diameters. 
Fig. 2. Fibrinous exudation after bronchitis, in the earliest stage of 

organization. 

A strong and otherwise healthy man, aged forty-one years, was 



536 



EXPLANATION OF THE PLATES. 



attacked with acute bronchitis in consequence of exposure to severe 
cold and wet. There was cough, sharp pain on inspiration, hoarse- 
ness, and expectoration, at first moderate, but afterwards very- 
copious, forming a thin yellowish fluid, which shewed under the 
microscope an immense number of pus -corpuscles ; on auscultation 
little respiratory murmur was heard, but general mucous rales. 
Membraneo-gelatinous masses were mixed with the expectoration, 
which was copiot^ charged with pus, and thrown off" to the amount 
of five or six ounces in the twenty-four hours. 

A mass of this kind of the size of a hazel nut appeared entirely- 
homogeneous, yellowish, and in places of a rusty tint : it resembled 
stiffening glue, but admitted of being drawn asunder, and divided into 
membranous layers. These layers formed perfect membranes and 
appeared entirely structureless and like coagulated fibrin — shew- 
ing neither granules or fibres (Fig. 2 A). The mass was opaque 
in the centre, and of a bluish yellow tint ; but transparent and almost 
colourless at the edges. 

Acetic acid rendered it more transparent ; nitric acid, and ammo- 
nia did not affect it ; but caustic potash rendered it more transpa- 
rent, and softer, without entirely dissolving it. It did not dissolve 
when boiled with concentrated hydrochloric acid, the colour of the 
acid as well as that of the membrane remaining unchanged even 
after prolonged ebullition. 

In some places this amorphous mass contained roundish, very- 
pale, colourless bodies (Fig. 2. B, cells ?) They varied from the 100th 
to the 60th of a line, and contained no nuclei — the first traces of 
cellular formation. 

Fig. 3. An unorganized coagulum of fibrin from the heart of a man 
aged fifty- six years — constituting false polypus of the heart. 
Both ventricles contained thick coagula of a white colour, which 
were closely combined with the columned earner, and could only be 
separated piecemeal with great difficulty. The observation of the 
progress of the disease rendered it probable that these coagula had 
been formed about ten days before death, while the patient remained 
for several hours in a state of syncope, without any evidence of a 
pulse. The coagulum in the left ventricle was very thick and firm, 
of a faint red colour; in the interior it was soft, being saturated with a 
yellowish white fluid, which was declared to be pus by the physi- 
cians in attendance. 

Under the microscope the coagulum appeared as a perfectly struc- 
tureless mass, which was covered by a large number of globules and 



EXPLANATION OF THE PLATES. 



537 



granules of fat : it contained no trace of cells. On the application of 
acetic acid, the amorphous mass became very pale, and so translu- 
cent as almost entirely to escape observation ; but even then no 
traces of nuclei or of commencing organization were visible. The 
fatty parts were not changed by the acid. The supposed pus in the 
interior contained no pus-corpuscles, but simply many globules and 
granules of fat in a colourless fluid. 

The same was the case with the coagulum L the right ven- 
tricle. 

Fig. 4. Exhibits fibrinous exudation in the act of development, 
from the arcus aortce of a man who had died from inflammatory 
hypertrophy of the heart with deficient action of the valves. 
The arcus aortce was externally reddened and covered with coagulated 
exudation, which was of a yellowish white colour, soft, saturated 
with a yellowish white thickish fluid smooth and fatty to the touch, 
and formed irregular portions of tolerable thickness. 

Under the microscope the exudation appeared like an amorphous 
mass of an indefinite fibrous character (Fig. 4. A). It became paler 
and more transparent on the application of ammonia, as well as of 
acetic acid. 

This amorphous mass contained a large number of cells of round, 
or roundish shape, varying from the 200th to the 100th of a line in 
diameter, and, for the most part, pale and without evident nuclei. 
There were, however, a tolerable number of little roundish granules, 
but it was impossible to determine with certainty, whether they were 
contained in the interior of the cells, or whether they were situated 
on their exterior. These granules were not affected by water, com- 
mon spirit of wine, caustic ammonia, caustic potash, or acetic acid, 
but dissolved in ether, in which they united and formed large fatty 
globules : they consisted, therefore, of fat. 

The cells became paler and gradually disappeared on the addi- 
tion of ammonia, which also rendered the amorphous exudation 
paler, and, by prolonged application, softer, and more fibrous. In 
some parts of the exudation the cells preponderated, in others, on 
the contrary, the amorphous stroma. No free fat appeared in the 
exudation. 

The pus-like fluid expressed from the mass showed under the 
microscope many isolated cells B, which were precisely similar to 
those contained in the exudation ; behaving in the same manner 
towards chemical agents. 

Fig. 5. Fibrinous exudation in the act of development, from an in- 
flamed lung. 



538 



EXPLANATION OF THE PLATES. 



The patient, a coachman aged forty years, addicted to drinking, 
entered the hospital at Munich, with all the symptoms of inflamma- 
tion of the right lung. Fever with hard full pulse, severe pain on 
breathing, oppression at the chest, and cough with sanguineous expec- 
toration. In the lower part of the right lung the respiratory sounds 
could not be heard, but crepitation was distinctly audible. On the 
seventh day of the disease the local symptoms yielded to an antiphlo- 
gistic treatment — venesection and the internal use of large doses of 
tartarized antimony. The sounds on percussion continued to be dull, 
but instead of the crepitation there was a loud mucous rattle, and the 
expectoration became more copious. This was succeeded by a 
general prostration of strength, the pulse was more frequent — small 
and weak ; there was great distension in the region of the stomach, 
vomiting, and death. 

On dissection there was fatty degeneration of the liver in an ad- 
vanced stage. 

The lower part of the right lung (the middle and lower lobes) was 
thickened, of a grayish red colour, which gradually became of a 
bright red on exposure to the air, and exhibited a granular appearance, 
when cut : it did not crepitate, and sank in water. 

The fluid from the thickened part of the pulmonary tissue was not 
frothy : it exhibited no air under the microscope, but a good many 
unchanged blood- corpuscles, and numerous pale cells varying from the 
200th to the 100th of a line, some of which contained nuclei with or 
without nucleoli, and others a granular mass in a larger or smaller 
quantity, (Fig. 5, A B). The cells appeared sometimes isolated as at A, 
sometimes united, in groups as at B. By the cells, fibrinous coagula 
of grape-like, or simply globular shape were seen, which in form and 
size corresponded with the air-cells of the lung. These coagula, 
when examined under the microscope, were seen to consist of an 
amorphous mass (C) which contained cells filled with granules, and 
likewise isolated granules. The fibrin was here in the act of being 
converted into granular cells. 

Larger portions of the thickened tissue of the lung appeared under 
the microscope (Fig. 5. D) as an indistinct granular mass with very 
many small granules, and roundish granular heaps from the 200th 
to the 100th of a line in diameter — granular cells. In some parts of 
the pulmonary tissue, the amorphous fibrinous exudation preponde- 
rated, while in others it was almost entirely converted into granu- 
lar cells. 



EXPLANATION OF THE PLATES. 



539 



PLATE III. 

PUS AND GRANULAR CELLS. 

The three first figures exhibit normal pus from abscesses of the cel- 
lular tissue. Magnified 410 diameters. 

Fig. 1. Shows pus-corpuscles (a) dark and compact, and covered with 
numerous granules. Besides the pus-corpuscles, we see many 
smaller granules (b) partly isolated, partly united. They consist of 
fat— a mixture of olein and margarin. 
Fig. 2. Also normal pus, showing very soft, pale pus-corpuscles, 
which do not appear perfectly round, and are only covered by a 
few granules. At (b) we see the nucleus appearing through the 
delicate capsule. This pus contains no fat granules. 
Fig. 3. Pus- corpuscles treated with acetic acid. 

The acid has more or less completely dissolved the walls, and only 
left the nucleus remaining. At a we see a triple, at b a single nu- 
cleus, still surrounded by the faint remains of a wall. At c and d 
the wall is quite dissolved and the mere nuclei remain. The cup- 
like form of the nucleus on treating it with acetic acid, is the one 
common to normal pus-corpuscles. 

Fig. 4. Supposed pus (magnified 220 diameters) from the pelvis of 

the kidney of a patient, who died of empyema. 

The pelvis of each kidney was completely filled with a yellowish 
white creamy fluid, which bore a perfect resemblance to pus : but on 
examination under the microscope nothing could be seen but por- 
tions of epithelium mixed with a colourless fluid (urine) ; a, a por- 
tion of epithelium varying between the cylindrical and pavement 
forms ; b a single epithelial cell of this kind ; c cylindrical epithe- 
lium seen from one side ; d a portion seen from above. 
Fig. 5. Exudation in the act of conversion into pus: from the pleural 

sac of a patient who died from empyema. 



540 



EXPLANATION OF THE PLATES. 



In the pus discharged from the pleural sac, there were several 
concretions varying from the size of a pea to that of a nut, of a 
whitish colour and admitting of being easily torn. When examined 
under the microscope, they were found to consist of an indefinite 
fibrous mass, enclosing numerous pus-corpuscles. These fibres were 
observed crossing each other in every possible direction. On the 
addition of acetic acid the fibrous mass entirely disappeared, leaving 
nothing but the nuclei of the pus- corpuscles. The whole substance, 
including the corpuscles, was entirely soluble in caustic potash. Mag- 
nified 220 diameters. 

Fig. 6. Exhibits the formation of pus in mucous membranes. In 
the fluid cytoblastema which is secreted, we observe the nuclei 
first produced, and around them the capsules gradually forming. 
Magnified 220 diameters. 

A girl suffering from empyema, suddenly commenced to expecto- 
rate very abundantly — in fact, to the amount of several pounds 
daily. It was perfectly fluid, creanry in appearance, and of a whitish 
yellow colour. Under the microscope there were seen (A) a very 
few perfect pus-corpuscles (a. a), which were very delicate and pale, 
while there was an increased quantity of nuclei of pus -corpuscles — 
single, double, and triple (b. b. b). On the addition of acetic acid 
there was a slight coagulation of mucus (see the lower portion of 
fig 6) ; the nuclei of the pus- corpuscles underwent no change, but 
in those corpuscles which were perfectly formed, the capsules became, 
as usual, transparent, and the nuclei became visible(**). They had 
not the ordinary cup-formed shape, but had an ^indefinite roundish 
appearance. 

Similar appearances present themselves in all mucous membranes, 
in which there is a copious secretion of pus. 
Fig. 7 — 11. Various forms of abnormal pus. 
Fig. 7. Scrofulous pus, magnified 410 diameters. 

The pus was obtained from a swollen cervical gland of a young 
man, with a well-marked scrofulous diathesis. It had a viscid 
appearance, was white, and, as is generally the case with scrofulous 
pus, contained numerous whitish clots. The corpuscles "of this pus 
(A) deviated from the normal form ; they were smaller than usual, 
(averaging from the 400th to the 300th of aline,) irregularly roundish, 
rough, pointed, and almost angular. They disappeared on the addi- 
tion of acetic acid, but the characteristic nuclei (B) did not make 
their appearance. The acetic acid coagulated a considerable amount 
of a viscid matter (pyin ?) which enclosed the corpuscles, and formed 



EXPLANATION OF THE PLATES. 



541 



clumps of them (C) . A solution of alum acted in a similar manner. 
The clotted, caseous matter in this pus, exhibited, in addition to 
pus-corpuscles, stellar or striped portions of amorphous appearance, 
which were rendered transparent by acetic acid, and could no longer 
be detected by the eye (exudation not yet organized). 
Fig. 8 and 9. Pus from abscesses in the cutaneous glands. Magnified 
220 diameters. 

Fig. 8. Pus from a small abscess on the inner surface of the root of 
the nail of the second toe of a healthy man. 

The pus which was evacuated by a puncture amounted to only a 
few drops, and was very thick. When examined under the micro- 
scope, there were observed not only pus and blood-corpuscles, but 
also modified epithelial cells (A), which varied in diameter 
from the 75th to the 100th of a line, and were partly round 
(a b c), and partly oval (d). Some consisted of a large dark nucleus 
varying from the 110th to the 180th of a line, surrounded by a 
transparent capsule (a), while others exhibited a clear nucleus and 
nucleoli in a dark capsule (b — d). 

On the addition of acetic acid, the pus- corpuscles underwent the 
ordinary change, the larger corpuscles being rendered paler and more 
transparent (B). There was also an abundant coagulation of mucus 
(pyin ?), forming a delicate membrane. 

Fig. 9. Pus from a minute abscess in one of the cutaneous glands in 
the nose of a healthy man. 

Under the microscope the fluid was seen to contain a very large 
number of pus-corpuscles, most of which were perfectly round, and 
exhibited no nuclei (a). They were very unequal in size, varying 
from the 170th to the 300th of a line in diameter; the average 
diameter was the 250th of a line. Many were united in a tesselated 
manner, forming a species of membrane ; hence they were somewhat 
angular (b. b). These appeared to be extremely delicate. Amongst 
them were a few non-nucleated epithelial cells (?) of which some were 
granular { c), but the majority exhibited a smooth surface (d) ; these 
were united so as to form membranous patches. On the addition of 
acetic acid the pus-corpuscles underwent the ordinary change (B), 
while the epithelial cells were unaffected. Moreover the acid coagu- 
lated a viscid mass, which enclosed the pus-corpuscles and epithelial 
cells. 

Fig. 10. Abnormal pus from the lung of a person who died from 
typhus. 

The lung was very dense and hepatized ; it sank in water, did not 



542 



EXPLANATION OF THE PLATES. 



crepitate, and on making a recent section, exhibited a dark violet 
tint. It appeared, on making a microscopic examination, that it 
contained no air, but much blood ; when this was removed by wash- 
ing, the pulmonary tissue appeared to be everywhere filled with pus. 
The corpuscles of this pus (A and B) deviated in some respects from 
the ordinary type ; their form was more irregular than usual, they 
were not perfectly round, many of them being elongated, and some 
a little angular ; their margin was for the most part very sharply 
defined, and their surface not so granular as usual. In size they 
varied from the 500th to the 150th of a line. On the addition of 
acetic acid they underwent the ordinary change ; their capsules 
became transparent, and as they gradually disappeared, the nuclei 
came in view ; they did not, however, exhibit the ordinary cup -shaped 
form with any distinctness (C and D). Ammonia entirely dissolved 
both capsules and nuclei. A, B, and C are magnified 220, and D 
410 diameters. 

Fig. 11. Pus from what is called a cold abscess on the right shoulder 
of a vigorous young man. Magnified 220 diameters. 
The pus which was discharged amounted to about two ounces ; 
it consisted of a rather thin, pale yellow fluid, and delicate thready 
flocculi of a yellow tint ; hence it differed essentially from good 
creamy pus. It had a strongly alkaline reaction. 

The microscope revealed the presence of pus-corpuscles, almost 
all of which were transparent and delicate, with a distinct margin ; 
and some slightly, others not at all granulated. In some the nucleus 
could be seen through the capsule (A). On the addition of acetic 
acid there was an abundant coagulation of an am orpho- fibrous cha- 
racter ; and on the addition of alum there was an abundant coagula- 
tion of a granulo -amorphous character (pyin ?) 

The yellow filamentous flocculi which were swimming in the fluid 
consisted of accumulations of minute and imperfectly formed pus- 
corpuscles, which were connected in irregular groups by an indis- 
tinct granulo-fibrous medium of communication. On the addition of 
acetic acid, this combining tissue became somewhat paler, without, 
however, disappearing ; and numerous fat-granules came in view. 
Ammonia produced little effect on this granular matter. 
Fig. 12 — 15. Granular cells (Gluge's compound inflammatory glo- 
bules, exudation- globules), magnified 220 diameters. 
Fig. 12. Elucidates the development of granular cells. All the cells 
in this figure were obtained from the same inflamed lung. At first 
we perceive the granular cells as simple cells without granules, 



EXPLANATION OF THE PLATES. 



543 



with decided nuclei and nucleoli (a. a.) These cells are for the 
most part round, but sometimes elongated or even angular. Their 
size varies from the 300th to the 100th of a line. We afterwards 
observe these same cells more or less covered with minute granules, 
varying in size from the 800th to the 1500th of a line. At first 
(in b. b.), as long as the granules are only sparingly present, it is 
difficult to distinguish whether they are on the surface or in the 
interior of the cells. 

Finally, when the whole cell is filled with granules, the nucleus 
cannot be discovered (d), and it can no longer be doubted that 
the whole of the interior of the cell is filled with granules. These 
granules appear to consist of fat. 

Fig. 13. Perfectly developed granular cells from inflamed lungs. 
A. from the lung of a man who died from pneumonia. The 
lung was in a condition of red hepatization. B. from the lung 
of a girl who died from pleuritic effusion. The left lung was 
very much compressed by the effused fluid, was of a brownish 
colour, contained no air, did not crepitate, and sank when placed 
in water. Under the microscope its tissue appeared unchanged, 
except that an immense number of granular cells were deposited 
in it. 

Fig. 14. Granular cells in the act of breaking up, and their remains. 

When the granular cells have attained their full development, the 
cell- wall disappears, and the granules contained in the interior are 
liberated, and form larger or smaller heaps. 

The granular cells in this figure were obtained from the lungs of 
an aged woman who died from pneumonia. The right lung was 
dense, red, hepatized, and contained no air. Under the microscope, 
the whole pulmonary tissue appeared filled with these cells, in various 
stages of disintegration. 

Fig. 15. Granular cells from an inflamed and softened liver. 

Fig. 16. The corps granuleux or colostrum- granules of the milk, 

obtained from the duct of an extirpated scirrhous breast. Magnified 

220 diameters. 

They are given in this Plate, since, from their similarity, they might 
be mistaken for granular cells. 



544 



EXPLANATION OF THE PLATES. 



PLATE IV. 

EPIGENESIS OF AREOLAR TISSUE AND ORGANIC MUSCULAR FIBRE. 

Fig. 1 . Newly formed areolar tissue, in various stages of development, 
from a false membrane in the pleura. 

A young man was attacked with inflammation of the right pleura, 
which was succeeded by very considerable empyema. As the diffi- 
culty of respiration was so great as to threaten daily suffocation, 
paracentesis thoracis was had recourse to, by which a very considerable 
amount of fluid was discharged. The fluid coagulated spontaneously, 
and had the same chemical composition as the plasma of the blood. 
It was again formed with such rapidity, that the operation had to be 
twice repeated. Soon after the last operation (on which occasion 
the fluid did not spontaneously coagulate, but was a mere admixture 
of serum with a little pus), the patient died. 

On dissection, the right pleura was everywhere invested with a 
false membrane, which formed a shut sac, containing a yellowish 
serum with a deposit of blood -corpuscles. This membrane varied 
in thickness from half a line to a line ; when examined under the 
microscope, it was found to exhibit traces of more or less advanced 
organization. The most recent layer, lying next to the pleural 
cavity, was partially fibrous, and contained many nuclei (A), toge- 
ther with numerous globules and granules of fat. On the addition 
of ammonia it became pale and transparent, the fatty granules being 
the only element unaffected by this re-agent. The mass that pre- 
sented itself after the removal of the most recent layers, consisted of 
irregular, for the most part elongated, membranous particles (cells, 
B), containing one or more nuclei. Some of these cells were 
very irregular and composite (B. a.), while others had the ordinary 
form of the caudate, fusiform, fibrous cells of areolar tissue (B. b.) 



EXPLANATION OF THE PLATES. 



515 



Acetic acid produced a paleness and transparency of the walls of all 
these cells without altering their nuclei. 

In the older layers adjacent to the pleura, the development of the 
fibrous cells of areolar tissue was still farther advanced. The cells 
were much elongated, and sharp at the two extremities, but still 
retaining the nucleus (C.) Other cells (D) formed parallel fasciculi 
of the fibres of areolar tissue, in which the nuclei were apparent. 
On the addition of ammonia, both the fibres and the nuclei gradually 
disappeared. 

Fig. 2. Areolar tissue, in part fully developed, and in part immature, 
from a false membrane from the pleura of another man, a muscular 
agricultural labourer, aged thirty-three years, who was attacked 
with pleuritis of both sides, and after six weeks maltreatment at 
the hands of a quack, was brought in a moribund condition into 
the Munich Hospital. 

On dissection, the pleural cavity on each side was invested 
throughout with a layer of solid exudation, varying from one to two 
lines in thickness. 

Shreds and flocculi were attached at various spots to the inner 
surface ; they were of a yellow colour, and their formation was 
obviously of the most recent date. They were soft, resembling 
coagulated and washed fibrin, and formed irregular patches, of vary- 
ing thickness. Under the microscope they appeared perfectly amor- 
phous, but at some spots exhibited a slightly fibrous structure. On 
the addition of acetic acid they softened, became transparent and 
gelatinous : they showed no trace of organization. 

The older portion of exudation, lying directly in contact with the 
pulmonary and costal pleura, formed a regular layer, of tolerably 
equal thickness, which, with careful dissection, admitted of separation 
into several strata. This portion was not so soft as that previously 
described, but was almost cartilaginous, and did not assume a mem- 
branous form. It exhibited indications of organization in proportion as 
the exudation approximated to the surface of the pleura, or in other 
words, in proportion to its age. 

The organization consisted in the formation of cells and in their 
conversion into fibres (Fig. 2.) The younger cells were fusiform, 
with a distinct nucleus (a.) Other cells, in a more advanced 
stage of development, consisted of thin parallel fibres, and formed a 
fasciculus of fibres of areolar tissue with nuclei (b.) 

In the layer of exudation in contact with the pleura, these cells 
undergoing conversion into fibres, were compressed on one another 
(c), and the newly formed areolar tissue could only be dis- 

VOL. J. N N 



546 



EXPLANATION OF THE PLATES. 



tinguished from the normal areolar tissue of the pleura by its less 
marked fibrous character, and by the presence of many nuclei. The 
nuclei were roundish, oval, caudate, or oat- shaped ; some contained 
nucleoli, others were devoid of them. In no place could their elon- 
gation into fibres be observed. On the addition of acetic acid, these 
newly formed fibres of areolar tissue became pale, and gradually 
disappeared ; the nuclei remained unaffected. 

Fig. 3. Illustrates the epigenesis of organic (involuntary) muscular 
fibre. The structures depicted are primary cells from a fibrous 
tumour in the uterus. They represent, in all probability, the 
earliest stage of the development of organic muscular fibre ; and 
it is only very rarely that we have an opportunity of observing 
them. The following is the history of the case. 
A female servant, aged forty-four years, was admitted into the 
Munich Hospital on account of severe abdominal pains. Her state- 
ment was, that for several years there had been a fluctuating tumour 
on the right side of her abdomen, but which had never hitherto 
caused her further pain or uneasiness than an occasional sense of 
weight or bearing down, as if in labour, until just before admission, 
when there had suddenly occurred in it most intense pain, with ten- 
derness on pressure. In defiance of the most energetic treatment — 
venesection and palliatives — this pain rapidly grew worse, and the 
woman died on the third day after its first occurrence. 

On dissection, the following appearances presented themselves. 
The right side of the great omentum was considerably thickened, and 
inseparably united on the one hand with the walls of the abdomen, on 
the other with a firm tumour, which extended downwards into the 
cavity of the pelvis, and was of about twice the size of a man's fist. 
The surface of this tumour was somewhat tuberculated, and of a 
whitish colour. It was intimately connected with the fundus of the 
uterus. The upper part of this tumour had began to soften, and its 
substance was here and there hollowed out into irregular excavations, 
which were traversed by bands and shreds of tissue, soft and friable 
externally, but tolerably firm in their interior. 

These excavations were partly empty, partly filled with small 
grumous masses of blood, or with a greasy, grayish- white, purulent- 
looking matter. The softening which was going on in this tumour 
had at one part approached quite to the surface, burst, and a portion 
of the softened matter had escaped into the cavity of the peritoneum, 
inducing secondary peritonitis, from which had resulted the sudden 
severe pain, so speedily followed by death. 

The inner surface of the uterus was healthy, its mucous membrane 
being unaltered ; but within its cavity was situated a roundish 



EXPLANATION OF THE PLATES. 



547 



tumour, about the size of a billiard-ball, tolerably firm, of a bluish- 
white colour, and covered on its surface with a yellowish purulent- 
looking matter. It lay quite free in the cavity, having no connection, 
at any part, with the walls of the uterus. The parietes themselves 
were very thick ; the degree of their thickness, however varied, being 
in some places as much as three inches. Imbedded within their sub- 
stance were found numerous roundish tumours, of all sizes, from that 
of a pea, to that of a billiard-ball. These tumours, for the most part, 
lay free, or at least so nearly free, that they could be separated 
without any difficulty from the substance of the uterus, within which 
they were imbedded ; they were of a whitish colour, very firm in 
texture, and of a globular form, though most of them were irregularly 
tuberculated and nodular. When cut into, each tumour was found 
to consist of a firm, compact, polished, white tissue, but with the 
naked eye no trace of a fibrous or other well-marked structure could 
be discerned. In the vaginal portion of the uterus was situated 
another tumour, about the size of a pigeon's egg, somewhat soft in 
consistence, and inseparably connected with the substance of the 
organ ; it had a whitish colour, and when cut into was found to be 
made up of a fibrous net-work, the areolae of which were large, and 
filled with a thick albuminous fluid. 

A careful microscopic examination of the several parts described 
above, furnished the following results. The substance of the 
uterus was composed of its usual organic muscular fibres, from the 
150th to the 300th of a line in diameter. Here and there, between 
these fibres, were scattered numerous granular cells, of a dark 
brownish colour such as are depicted in Plate in. fig. 12 — 15. 
The tumour, which was situated within the cavity of the uterus, 
presented a structure almost exactly similar to that of the uterus 
itself, being made up of fibres closely resembling those peculiar 
to organic muscle, and containing also the same dark-looking 
granular cells noticed between the fibres of the uterus. Similar 
characters were also presented by those tumours, both large and 
small, which were imbedded within the parietes of the uterus. 
The softened mass at the upper part of the large tumour, which was 
situated outside the uterus, contained, besides small grumous masses 
of blood and separate blood- corpuscles, numerous pus-corpuscles, the 
presence of which justified the supposition that the softening of the 
tumour was the result of inflammation. The usual changes were 
produced on these pus- corpuscles by the addition of acetic acid, 
namely, the gradual disappearance of the cell- wall of each, and the 
coming into view of its double or triple nucleus ; the nuclei were left 

N N 2 



548 



EXPLANATION OF THE PLATES. 



entangled in a coagulum formed by acetic acid, and consisting of a 
perfectly amorphous structureless mass, resembling coagulated 
mucus (pyin ?). The bands and shreds of tissue which traversed the 
excavations in this softened part, exhibited beneath the microscope 
the remains of areolar tissue, which had resisted the process of 
softening and destruction. The soft tumour situated in the vaginal 
portion of the uterus, seemed to be a fibrous tumour in the process 
of formation ; for the fibrous portion consisted of organic muscular 
fibre and areolar tissue, and the albuminous fluid which filled up the 
meshes, exhibited, under the microscope, numerous roundish or oval 
cells, some single, others arranged in groups, containing nuclei 
and nucleoli, (see Fig. 3.) ; these were, in all probability, primary 
cells, which would eventually have become developed into organic 
muscular fibres. 

Several of the other tumours contained in the substance of the 
uterus, were carefully removed, cut into small pieces, and after being 
repeatedly washed, were subjected to several chemical tests. They 
gradually dissolved in boiling concentrated hydrochloric acid, forming 
a colourless solution. In acetic acid they swelled up, became trans- 
parent and gelatinous -looking, but a complete solution was not 
effected even after the lapse of some weeks. Several pieces from these 
tumours, after being repeatedly washed and dried with blotting-paper, 
were weighed, then thoroughly dried in a water -bath, at a tempe- 
rature of 212° F., and again weighed. Of 1000 parts of the fresh 
substance, there remained, when thus thoroughly dried, only 220 ; 
consequently 780 parts consisted of water and other matters, volatile 
at a temperature of 212° F. 

Fig. 4. Newly-formed organic muscular fibre from the hypertrophied 
muscular coat of the intestine of a man who died from peritonitis. 
The muscular coat at the commencement of the caecum was a line 
in thickness. 

A. Is a thin section made by the double knife, as seen under the 
microscope. We observe parallel fibres with nuclei. 

B. Are individual fibrous cells in the course of development into 
muscular fibres. 

C. Is a very thin section treated with acetic acid ; the fibres are 
very pale, and the nuclei are distinctly visible. 



EXPLANATION OF THE PLATES, 



549 



PLATE V. 

EPIGENESIS OF BLOOD, BONES, NERVES, AND SEROUS MEMBRANES. 

The Figures from 1 to 4 illustrate the pathological epigenesis of 
of blood in the adult. The following case will serve as an illus- 
tration. 

A young man, aged twenty years, suffered from encephaloid of the 
left arm, which slowly developed itself, and finally ulcerated. Re- 
peated haemorrhages rendered amputation necessary. The amputated 
part could not be obtained for microscopical examination. About 
ten days after the amputation, fungoid growths, which came from 
the medullary cavity of the bone, appeared. When removed, they 
were of a whitish-yellow colour, soft, fatty, and anaemic. When 
examined under the mieroscope, they were found to consist of areolar 
tissue in the act of development, (granulations). 

Two days subsequently, on renewing the bandage, another growth 
from the medullary cavity of the bone, of precisely similar appear- 
ance, was observed. It was as large as a cherry, and externally 
brown, (being discoloured by the liniment, ex. pulv cort. china;), and 
shrivelled, and internally of a yellowish- white, lardaceous appearance. 
Its consistence was so soft and mellow, that it could easily be broken 
off by the finger without the assistance of any sharp instrument. 
It had sprouted from the medullary cavity of the bone. 

Under the microscope, it appeared throughout as a granulo-amor- 
phous mass, which, on the addition of acetic acid, became pale and 
transparent. It was almost wholly unorganized, only exhibiting at 
a few spots traces of cells, partly of indefinite form, and partly 
elongated, (the fibrous cells of areolar tissue). 

A recent section of the mass (Fig. I. left side) showed many small 
points and streaks of blood. These small portions of blood in the 



550 



EXPLANATION OF THE I'LATES. 



midst of the mass, without any connection with the vessels of the bone, 
must necessarily, from their place and position, have been formed there, 
and promised to afford some elucidation of the morphology of the 
formation of the blood, which can so seldom be directly observed. 
The result of a careful examination was as follows. 

All the newly formed portions of blood were very large, and 
visible even to the unaided eye, as streaks or points ; where the naked 
eye discovered no blood, none was to be seen under the microscope. 
It seems, therefore, that the larger and not the smallest capillary 
vessels are first formed. 

The form of these masses of blood varied considerably, being some- 
times roundish, or quite indefinite (Fig. 1.), sometimes elongated 
(Figs. 3 and 4), while at other times, several portions were united 
together in a star-like figure (Fig. 4). The masses of blood were not 
definitely circumscribed, and gradually lost themselves in the paren- 
chyma ; there were not as yet formed any proper vessels of uniformly 
equal diameter, and distinct vascular walls were still wanting. It 
is only in Fig. 4 that there is any indication of a distinct separa- 
tion of the vessels from the parenchyma, The colour of the blood 
was even now red, varying from a pale yellowish red where it was 
thin and dispersed, to a dark red where the mass appeared more 
closely arranged. The blood was fluid, and could be pressed from the 
parenchyma ; it shewed also clearly defined blood-corpuscles, which 
lay partly scattered separately in the parenchyma (Fig. 1), and 
partly collected in larger masses (Fig. 3 and 4) ; the former was 
rarely observed. There was no evidence of a development of these 
accumulations of blood-corpuscles in common cells, (vascular cells). 

The individual newly formed blood-corpuscles (Fig. 2), were some- 
what smaller than common ; their diameter was the 600th, the 500th, 
or at most, the 400th of a line, and they had not the usual cup-like 
central depression, but were irregularly spherical and angular. Some- 
times they appeared separate, sometimes several were united together. 
On the addition of water, they became pale and gradually disap- 
peared ; the same thing occurred, but more rapidly, with acetic acid. 
There was no trace of nuclei. 

This blood had evidently originated in the interior of the paren- 
chyma (plastic exudation), and at first in portions which corres- 
ponded with the future larger vessels. It had not been formed in 
vascular cells, but free in the parenchyma, and appeared earlier than 
the vessels. It was formed sooner and more rapidly (in less than 



EXPLANATION OF THE PLATES. 



551 



two days), than any of the tissues, even earlier than the areolar 
tissue. 

Fig. 1. On the left hand shows a recent section of the fungoid growth 
in its natural size, with distinct points and streaks of blood. 

Fig. L On the right hand, exhibits newly formed blood- corpuscles, 
partly separate, and partly united in groups, scattered in the 
parenchyma. Magnified 220 diameters, a. blood-corpuscles ; 
b. fat-globules. 

Fig. 2. Separate, newly formed blood-corpuscles, magnified 410 
diameters. 

Fig. 3. Annular accumulation of blood, in which the corpuscles can 
be distinctly seen merging into the parenchyma. Magnified 220 
diameters. 

Fig. 4. Larger star-like or radiating patch of blood, magnified 67 
diameters. The vascular walls can be already traced ; the masses 
of blood are still unorganized and confused ; the separate blood- 
corpuscles not being evident even under a strong power. At ** 
globules of fat are scattered in the parenchyma. 

Fig. 5. and 6. Exhibit a perfect morbidly formed serous membrane 
with epithelium, which had been repeatedly in a state of inflamma- 
tion. It likewise affords an illustration of the epigenesis of vessels. 
Magnified 160 diameters. 

A girl, aged twenty years, died after having frequently suffered 
from pleurisy. The left pleural cavity contained about three quarts 
of a clear limpid fluid. It was inclosed in three sacs, lying within 
one another. The outer one was the normal pleura ; the inmost one 
formed a structureless, perfectly amorphous mass, without any con- 
nection with the middle one, of which it was an inflammatory pro- 
duct. This middle sac was loosely united to the costal pleura and 
the diaphragm, (somewhat more firmly with the latter,) by means of 
areolar tissue and vessels, and was attached by adhesions to the peri- 
cardium; forming a perfectly independent membrane, which was 
clearly distinct from the subjacent normal pleura. It varied from 
half a line to a line in thickness; externally it had a glistening 
appearance ; internally it was at spots of a bright red colour. 

It showed under the microscope (Fig. 5), a very thick net- work 
of perfect, distended (inflamed) blood-vessels. A granular epithelium 
(Fig. 6) could be scraped off its inner surface. The tissue of this 
false membrane histologically resembled normal serous membrane. 
It consisted of bundles of the normal fibres of areolar tissue, which 



552 



EXPLANATION OF THE PLATES. 



were interlaced and crossed in various directions. In many places 
this areolar tissue was still in the act of development ; we could 
observe nucleated cells, which were being elongated at both extre- 
mities, and nuclei which rested upon the perfect fibrous bundles. On 
the external surface nearest the pleura, the tissue of the false 
membrane was firmer, and could not be drawn asunder into fibres. 
Under the microscope it exhibited fibres, which were not twisted like 
those of areolar tissue, but straight, stretched out, frequently divided, 
and even branched, and when seen en masse, of a darker brown colour, 
resembling the elastic fibre of the arterial membrane, more than that 
of areolar tissue. 

Fig. 5. Free surface of the false membrane, with a perfect net- 
work of vessels in a state of congestion. 

Fig. 6. Nucleated epithelium of the false membrane. Both figures 
magnified 160 diameters. 

Fig. 7. to 9. Illustrate the pathological epigenesis of osseous tissue. 
They exhibit the internal structure of a newly formed lamina of 
bone, which was found in the dura mater of an old apoplectic sol- 
dier. The bone was flat, about the size of a fourpenny-piece, and 
lay in the falx cerebri, between the layers of the dura mater, at a 
spot corresponding with the anterior third of the commissure. All 
the figures are magnified 220 diameters. 

Fig. 7. From the edge of the piece of bone : it seems to be the most 
recently formed, and still imperfectly ossified. In a still amorphous 
streaky blastema («. a.), lie transparent fusiform corpuscles (* * *) 
—the future bone- corpuscles ; they contain as yet no calcareous 
salts, and are therefore pale and transparent. 

Fig. 8. Section of the piece of bone, parallel to its long diameter. 
At A, we see the opening of an osseous canal, the walls of which 
consist of concentrically disposed annular lamellse ; it has been 
somewhat obliquely cut. At B, the laminse run in a straight line 
parallel with each other, and with the surface of the bone. * * are 
bone- corpuscles, which run parallel with the direction of the 
laminae. 

Fig. 9. A section of the piece of bone at the pointed end, cut off 
at right angles to the surface. Darker and lighter laminae alternate 
with one another, parallel to the surface of the bone. The 
bone -corpuscles are not visible. 

Fig. 10. and 11. Show the regeneration of primitive nerve-fibre by 
a. morbid process. Both figures are copied from Steinriick, 



EXPLANATION OF THE PLATES. 



553 



(De Nervorum Regeneratione, Berol. 1833. PI. n. Fig. 5 
and 6). 

Fig. 10. A piece taken from a cicatrix on the infra- orbital nerve of a 
rabbit, from which a portion, a line in length, had been excised 
ten weeks previously. Magnified 430 diameters. Primitive nerve- 
fibres imbedded in areolar tissue. 

Fig. 11. Separate newly formed primitive nerve-fibres, precisely 
analogous to the normal uninjured primitive fibres of the same 
nerve. 



554 



EXPLANATION OF THE PLATES. 



PLATE VI. 

TUBERCLE ENCEPHALOID TYPHOUS MATTER. 

Fig. 1 . Exhibits tubercles fiom different organs, in various stages of 
development. 

Fig. 1. A — C. Tubercles from the lungs of a young man, who died 
of Tuberculosis pulmonum. A and B are nuclei in an amorphous 
cytoblastema ; most of these nuclei contain nucleoli. At C the 
cytoblastema has disappeared, and the cells are in contact with 
each other. The cytoblastema as well as the nuclei were soluble 
in ammonia. 

Fig. 1. D. Tubercular cells from the lungs of another young man, 
who died from the same malady. 

Here the cytoblastema has also disappeared, and the nuclei are 
enclosed in a cell- wall ; no nucleoli are present. The cell- wall 
gradually dissolved in acetic acid, the nuclei remaining un- 
changed. 

The lungs of both subjects contained, besides the true tuberculous 
cells, also many granular cells; those of the first-named subject 
presented many vomicae, which contained softened tubercular matter, 
as shewn in Fig. 6 of this Plate. Magnified 220 diameters. 
Fig. 2. Tubercles from the lungs of another young man. Magnified 

220 diameters. 

A. Nuclei, for the most part with nucleoli, in an amorphous cyto- 
blastema. 

B. Perfect tubercular cells with a cell- wall, nucleus, and nucleoli ; 
the former was soluble in acetic acid, which produced no effect on 
the latter constituents. 

C. Separate cells, with granular contents. 

D. Larger cells, frequently occurring in tubercle. 

Fig. 3. and 4. Tubercles from the kidneys and lung of a young 



EXPLANATION OF THE PLATES. 



555 



woman, who died from Phthisis tuberculosa renis dextri et pul~ 
monum. 

Fig. 3. Tubercles from the right kidney, which had been entirely 
destroyed by infiltration and partial softening of tubercular 
matter. They constituted a white lardaceous mass, which, 
when magnified 220 diameters, exhibited many round corpuscles 
(a, nuclei), in an amorphous mass (cytoblastema). 
Besides these, there were separate larger cells, some of indefinite 

form (b), and others much elongated, resembling the fibrous cells of 

areolar tissue (c). 

Fig. 4. Tubercles from the lung of the same woman. Magnified 
220 diameters. 

They exhibit a very great variety in the form of the cells, a. nuclei 
in an amorphous cytoblastema. b. large elongated cells, c. large 
round cells, partly with and partly without granules. These variously 
shaped cells appeared simultaneously in all parts of the tubercle, but 
the nuclei (a) were by far the most numerous. 

Fig. 5. A. Tubercles from the lungs of a soldier. Magnified 220 
diameters. The cellular structure was very distinct in them ; the 
cell- wall and nucleus with nucleoli were almost everywhere to be 
distinguished, and the separate cells showed less difference in form 
and size than usual. 

Fig. 5. B. Tubercles from under the peritoneum of a woman who 
died from dropsy. Magnified 220 diameters. They were depo- 
sited over the whole of the abdominal parietes, and in the mesen- 
tery beneath the peritoneal investment. They were about the 
size of a lentil, of indefinite form, tolerably firm, and of a larda- 
ceous consistence. Under the microscope there were seen nuclei 
in an amorphous cytoblastema (a), and perfect cells (b), which in 
form and in their chemical relations entirely resembled the cells of 
tubercle. 

Fig. 6. Dissolved tubercular matter from the kidneys of the same 
woman from whom the crude tubercles in Fig. 3 were depicted. 
The matter presented the appearance of a thick fluid, resembling 
scrofulous pus; it was not viscid, and did not form a jelly with 
ammonia like normal pus : under the microscope there were no pus- 
corpuscles to be seen, but an indistinct granular matter blended with 
isolated undissolved tubercular cells. Magnified 220 diameters. 
Fig. 7. Encephaloid of the bladder of a man aged sixty-six years. 

The bladder was entirely converted into encephaloid, and was 
much thickened (its walls being an inch in diameter); it was en- 



556 



EXPLANATION OF THE PLATES. 



larged externally, whilst its cavity was diminished, rough, un- 
even, and tuberculated on its external and internal surfaces. Besides 
the bladder, the inguinal glands of the right side, and the prostate 
were affected by the encephaloid. 

The malignant matter in the bladder was soft, brain-like, easily 
convertible into a pulp on pressure, and at some points had even 
liquefied. It was whitish, and fatty to the touch. 

A microscopic examination gave the following result : 

The encephaloid consisted wholly of cells of different size and 
form. They were partly round, partly oval, partly caudate, but no 
one form predominated over the rest. The roundish cells varied 
from the 100th to the 60th of a line in diameter, the elongated cells 
from the 50th to the 60th in length, and from the 100th to the 300th in 
breadth. The nuclei of the round ones were on an average the 
200th of a line in diameter, and those of the longer cells were nar- 
rower. Some cells appeared very large (even the 30th of a line) 
when they generally enclosed several minute cells with nuclei (a). 
Isolated cells, although in a proportionately small number contained 
dark granules (b). 

Acetic acid did not affect the nuclei, or the walls. Nitric acid 
caused the cells to adhere together, and to become entangled 
within an amorphous coagulum (albumen). Ammonia did not dis- 
solve the cells, but rendered them paler, while the nuclei disappeared. 
The dark granules remained unchanged. The encephaloid contained 
blood-vessels. The encephaloid of the inguinal glands was in every 
respect similar to that in the bladder, excepting in the former case it 
was evident that the encephaloid had been developed between fibres 
of areolar tissue. Magnified 220 diameters. 

The same figure serves to elucidate the appearances presented in a 
case of encephaloid of the stomach from an elderly woman who died 
from pneumonia. In the otherwise normal stomach, about two inches 
from the pylorus, there was in the smaller curvature, an elongated 
tumour three inches in length, and two in breadth. It formed a 
kind of roll consisting of several nodules, with an indentation in the 
middle ; the separate nodules varied from the size of a bean to that of 
a walnut. The whole tumour was covered over by the unaltered 
mucous membrane*; it was of a moderately hard consistence (some- 
what like that of steatoma) and was not soft in any part. On cutting 
it, it was of a yellowish white colour, and exhibited no trace of blood- 
vessels. A microscopic examination shewed it to consist entirely of 
colourless nucleated cells of different forms, which were united toge- 



EXPLANATION OF THE PLATES. 



557 



ther, as if tessellated, without any areolar tissue, and formed the 
tumour. These cells are depicted in the central portion of Fig. 7. 
The isolated cells were partly roundish or oval, and partly elongated, 
irregularly caudate ; they varied in length from the 1 70th to the 60th 
of a line, and in breadth from the 100th to the 200th, while the 
diameter of the nuclei varied from the 200th to the 300th of the 
same standard. Neither ammonia nor acetic acid dissolved them. 
Magnified 220 diameters. 

Fig. 8. Encephaloid of the uterus of an aged woman. 

The upper part of the uterus was in a normal condition, with the 
exception of a fibroid tumour of the size of a musket-ball, but the 
vaginal portion had become entirely encephaloid. Besides this a 
large encephaloid mass was found upon the psoas muscle of the left 
side. 

The encephaloid of the uterus was very soft . and of a white colour ; 
it exhibited different kinds of cells under the microscope — caudate 
cells with nuclei and nucleoli (a a) ; roundish cells also with the same 
(c) ; mere nuclei with nucleoli (b b) ; very large cells having in their 
interior many nuclei (d d) ; numerous globules and granules of olein 
and margarin (e) ; and crystals of cholesterin (/). The encephaloid 
covering the psoas muscle was precisely similar. Magnified 220 
diameters. 

Fig. 9. Encephaloid of the liver of a woman aged forty-eight years, 
in whom the bladder and the vaginal portion of the uterus had also 
become converted into an encephaloid mass. The liver was not 
enlarged, but filled in all its parts with a large number of circum- 
scribed yellowish white tumours of sizes varying from that of a pea 
to that of a walnut. They were of indefinite form, spherical, reni- 
form and knotty. They were accurately circumscribed, deposited 
in the normal parenchyma, and not prominent on the surface : they 
had a fibrous radiating structure, were tolerably firm, and exhi- 
bited no trace of softening. They contained vessels evident to the 
unaided eye. Under the microscope they appeared wholly composed 
of cells, which showed distinct nuclei with nucleoli. The cells 
were mostly roundish or oval, but some were caudate. Acetic acid 
rendered them pale and brought the nuclei plainly in view (a). 
Here and there mere nuclei were seen in an amorphous cyto- 
blastema, (b). Magnified 220 diameters. 
Fig. 10. A tumour supposed to be encephaloid, from the lung of an 
officer, who had often suffered from gonorrhoea. 
The lung contained a circumscribed tumour of the size of a wal- 



558 



EXPLANATION" OF THE PLATES 



nut, and of a reddish white colour. It was quite soft, could easily 
be reduced to a pulp, and resembled cerebral substance. From 
these physical characters, it was pronounced to be encephaloid of the 
lung. 

Under the microscope the tumour showed : 1 . A very evident net- 
work of capillary vessels, which were filled with blood (the lower 
portion of the figure.) Magnified 90 diameters. 2. The tumour 
consisted for the most part of little oleaginous globules varying 
from the 200th to the 1500th of a line in diameter (the upper por- 
tion of the figure). Magnified 220 diameters. They appeared in 
great quantities, and were soluble in ether and alcohol, in which they 
collected in large drops ; ammonia did not affect them. 

On the removal of these oleaginous drops by pressure and wash- 
ing, the normal substance of the lung remained without showing any 
trace of abnormal formation. The lung in the vicinity of the tumour 
was in a perfectly healthy condition. 

Fig. 11. Encephaloid from the inguinal glands of an aged woman. 

The uterus as well as the inguinal glands on the right side were 
attacked by encephaloid, which was similar in its microscopic and 
physical characters in both organs. It was of a yellowish white 
colour, fatty, and of the consistence of brain. Under the micro- 
scope its chief constituents appeared to be cells of irregular form 
varying from the 400th to the 150th of a line in diameter («). 
They were mostly round or oval, comparatively few being caudate. 
There w r as also much fat in minute granules and globules (6) : 
the granules were heaped together in large masses in some places 
(c). A few granular cells (d) were also present. Magnified 220 
diameters. 

Fig. 12 — 15. Typhous matter deposited in the various organs during 

the progress of typhus. 
Fig. 12. Typhous matter from the mesenteric glands of a girl aged 

fifteen years, who died of typhus. 

The patient was brought to the Munich hospital, after having 
been ill fourteen days, with a high pulse, and suffering from exces- 
sive heat. The lungs were less affected than usual, but the abdomi- 
nal organs were especially implicated, as shown by their tympanitic 
state, and profuse diarrhoea. Her strength failed suddenly, and death 
ensued on the eighth day after her admission into the hospital ; and 
at the height of the disease. 

On dissection, the brain and spinal cord were found to be normal ; 
the lungs were sound, but somewhat congested in their lower lobes ; 



EXPLANATION OF THE PLATES. 



559 



the spleen was rather softened ; but the intestinal canal presented the 
most important lesions. The lower part of the small intestines 
was much thickened, all the glands, both those of Peyer and Brun- 
ner, being infiltrated with typhous matter. All the glands of the 
colon were also swollen and thickened : the mesenteric glands were 
much enlarged. 

A few of the mesenteric glands, about the size of a bean, were 
carefully examined. They contained a soft medullary substance, 
which yielded readily to pressure. Under the microscope it appeared 
as an amorphous, slightly granular mass of a brownish white colour, 
in which an immense number of small cells were deposited (A). 

These cells had an irregularly roundish form ; they were mostly 
small, almost all under the 300th of a line in diameter; only 
a few measuring from the 150th to the 200th of a line. Some 
few of these cells exhibited a distinct nucleus. By treatment with 
acetic acid the amorphous mass was rendered transparent, and gra- 
dually dissolved, upon which many very minute cells (nuclei ?) with 
a sharp outline came in view (B), being unaffected by the acid. 
Ammonia and caustic potash dissolved the cells as well as the 
cytoblastema. 

The glands of the colon contained a similar mass. Magnified 220 
diameters. 

Fig. 13. Typhous matter from Peyer's glands. 

The patient, a shoemaker's boy, aged seventeen years, was 
brought into the hospital in a very dangerous condition. The abdo- 
minal organs were especially affected. He had violent diarrhoea and 
considerable meteorism. He died on the fifth day after his admis- 
sion, with the symptoms of perforation of the intestine. 

On opening the body, both lungs were found externally covered 
with a gelatinous exudation, (serum which had become infiltrated 
into the tissue of the pulmonary pleura.) 

The lungs themselves were tolerably healthy, but inferiorly they 
were in a state of congestion. The abdomen was much swollen and 
contained a very large quantity of sero-purulent exudation. The 
convolutions of the intestines were covered and partially agglutinated 
by a gelatinous exudation and by layers of coagulated fibrin. The 
mesenteric glands were much enlarged. The small intestine con- 
tained numerous ulcers ; almost all the patches of Peyer's glands 
being in an ulcerated condition, and at one spot having given rise to 
perforation. At the spots where there was ulceration, the mucous 
membrane with its investment of epithelium was wanting, and in its 



560 



EXPLANATION OF THE PLATES 



place was a yellowish white lardaceous mass (typhous matter). 
Under the microscope this substance appeared to be indefinitely gra- 
nular, amorphous, and of a brownish white colour. Both acetic 
acid and ammonia rendered it soft and transparent, much like coagu- 
lated fibrin. At various spots it contained irregular cells varying 
from the 300th to the 400th of aline in diameter (Fig. 13), and 
numerous fatty granules. Magnified 220 diameters. 
Fig. 14. Cells from typhous matter in Peyer's glands ; taken from a 

soldier who died whilst the disease was at its height. 

All Peyer's and most of Brunner's glands were thickened and 
infiltrated with typhous matter. There was, however, no appear- 
ance of ulceration ; the mucous membrane covering the infiltrated 
glands being perfectly entire, though highly reddened and vascular. 
The typhous matter, which was deposited between the muscular and 
mucous coats of the intestines, appeared to be generally amorphous, 
although in some places there was a distinct cell-formation. Most 
of these cells contained several nuclei (Fig. 14). Magnified 220 
diameters. 

Fig. 15. Typhous matter in the lowest stage of organization, from 
the lungs of a soldier. 

Both lungs exhibited in almost every part tubercular-like nodules 
of a yellowish- white colour. Microscopic examination showed that at 
those spots there was an entire deficiency both of air and blood ; 
neither was there any vestige of pulmonary tissue, but merely an 
amorpho- granular colourless mass covered with numerous fatty gra- 
nules. It exhibited no trace of cellular structure. On the addition 
of acetic acid this mass became transparent, and the normal pulmo- 
nary tissue which had been enclosed by it, was brought in view. 
Magnified 220 diameters. 



EXPLANATION OF THE PLATES. 



561 



PLATE VII. 

FATTY AND FIBROUS TUMOURS. 

Fig. 1. A fatty tumour (lipoma or steatoma). Magnified 160 dia- 
meters. 

A woman aged about forty years had several tumours on the head 
and neck. She had been operated on four times, but the tumours on 
each occasion reappeared. In September 1839, she entered the hos- 
pital at Erlangen for the purpose of being again operated on. At this 
period there were several tumours about her head and neck. There 
was one situated on the right side of the nose, extending from the 
root of this organ to the lower edge of the right ala, and so firmly 
attached to the subjacent bones that in performing the operation, it 
was necessary to remove the nasal bone, and the nasal process of the 
superior maxillary along with the tumour. 

There was another tumour seated at about tbe middle of the lower 
border of the inferior maxillary bone on the right side ; it was in close 
connection with an artery and vein, so that it was necessary to tie 
the former in removing the tumour. There was a third tumour 
situated in the middle line of the neck, about midway between the lower 
jaw and the larynx. Each of these tumours when extirpated, was 
found to be about the size of a small apple ; they were irregularly 
spherical and lobulated, had a lardaceous consistence, and were 
each enclosed in a thin cyst or capsule. These tumours exactly re- 
sembled each other as regards their histological characters ; they were 
each composed of fibres identical with those of ordinary areolar tissue 
(a), and of fat-cells {b), which corresponded exactly with those 
observed in common adipose tissue. Although there were no blood- 
vessels distinctly observed, yet they were undoubtedly present, though 
few in number, as is usually the case in adipose tissue ; the fact of 
vol. i, 6 o 



562 



EXPLANATION OF THE PLATES. 



their being so very indistinct in the present case is explained by the 
great loss of blood attendant on the necessarily prolonged operation, 
whereby these vessels would be almost completely drained of their 
contents. 

On examination under the microscope there were observed 
several drops of oil (c), which doubtless had been squeezed out 
of the fat-cells by the pressure of the glass placed over the object. 
These several elements of each of the tumours were disposed in the 
following order ; the fibres (partly separate, partly arranged together 
in undulating fasciculi, as observed in ordinary areolar tissues), 
formed the ground-work of the substance of the tumours, whilst 
between these fibres the fat-cells were deposited. The arrangement 
of the fibrous fasciculi followed no regular order ; they w T ere observed 
crossing each other in all possible directions. Where the substance of 
the tumours was most firm and deep, there the fibres especially pre- 
vailed ; where, on the other hand, the texture was soft and adipose, 
there the fat- cells were most abundant. In these latter parts, where 
the fat was most prevalent, the fat- cells were arranged in much the 
same order, as we observe to be the case with the cells of plants. At the 
parts where the tumours encroached upon the bone, the fat- cells were 
observed to be in contact with the osseous substance, which itself, 
however, was quite unaltered. The enclosing cyst or capsule was 
thin, fibrous, and made up of densely interwoven bundles of areolar 
tissue, crossing each other in all directions. It thus exactly resem- 
bled the structure of the membrane described as forming the cyst of 
a true encysted tumour. See Plate ix. Fig. 1 — 3. 
Fig. 2. Fibrous tumour. The fibres in this case resemble those of 
organic muscle, constituting the variety of tumour termed Fibroid. 
Fibroid from the stomach of a man aged forty-four years, who 
died from renal disease. Magnified 220 diameters. 

On the lesser curvature of the stomach and towards the cardia 
there was a morbid product of the size and form of an almond. It 
lay under the mucous membrane, or more correctly speaking, in the 
muscular coat ; was of a whitish colour, and in form and consistence 
resembled an extirpated tonsil. It was covered with a layer of cel- 
lular tissue, which separated it from the surrounding structures ; there 
was, however, no definite capsule or cyst. The interior of the tumour 
presented the same appearance as the exterior. A recent section had 
a milk-white colour, and appeared perfectly homogeneous ; it was 
very dense and unyielding, and tore on attempting to stretch it. 



EXPLANATION OF THE PLATES, 



563 



Under the microscope there were seen traces of vessels containing 
blood ; on the whole, however, it was anaemic. 

At the first glance the histological structure of the tumour was not 
very obvious. On more careful examination, however, there were 
seen on making a thin section, many nuclei with nucleoli (C), 
and some very delicate, tolerably broad, extended fibres, on many 
of which nuclei were apparent. (B & D). There were no 
fibres of areolar tissue. On the addition of acetic acid, the broad 
fibres became pale and gradually disappeared, leaving only the nu- 
clei. It was ascertained, by further investigation, that these broad 
fibres, which were perfectly identical with those of organic muscle, 
and ran to a parallel direction, constituted the whole tumour 
(A). They were not, however, very distinctly marked; the 
whole structure was to the highest degree delicate, and at some 
spots there was an amorphous blastema not yet developed into 
fibres, which on the addition of acetic acid became paler and less 
distinct. In what direction the fibres were arranged — whether they 
were concentric, circular, and parallel to the surface of the tumour, 
or whether their course was uncontrolled by any fixed order — could 
not, on account of their extreme delicacy, be ascertained. 
Fig. 3. & 4. Fibrous tumours, whose histological elements are 

identical with those of areolar tissue. 
Fig. 3. Histological elements of a fibrous tumour. Magnified 

220 diameters. 

A man suffered from a polypus attached to the posterior portion of 
the nasal cavity, and projecting backward into the pharynx. It was 
removed by making a section through the soft palate. The por- 
tion removed was very firm, vascular, and homogeneous ; when 
washed it had a white fibrous appearance. On microscopical exami- 
nation, its tissue was seen to consist of fibres of areolar tissue, for the 
most part in the process of development. They appeared more or 
less twisted or woven together ; and many of them exhibited nuclei 
with nucleoli. All the stages of the development of areolar tissue, 
which we have depicted in Plate iv. Fig. 1. & 2., were exhibited in 
this structure. 

A, Are primary cells, with nuclei and nucleoli. B, are the 
same cells elongated and becoming caudate. C is an indistinct 
fibrous blastema on which there are nuclei. D, very elongated cells . 
E, the same elongated cells loosely arranged together, so as to 
form fasciculi of areolar tissue. F, cells which, by a sort of 

o o 2 



564 



EXPLANATION OF THE PLATES. 



channelling, separate into numerous fibres. G, a portion of the 
mature fibres of areolar tissue. 

On the addition of acetic acid, a portion of the mass became 
transparent ; numerous isolated nuclei were then seen, as well as 
many unaltered fibres, in a semi- amorphous mass. The arrangement 
of the fibres appeared to be generally circular or spherical. 

The entire polypus was invested with a normal mucous membrane, 
the surface of which was protected by several layers of pavement- 
epithelium. No ciliated epithelium could be observed. 
Fig. 3*. A, represents a patch of non-nucleated epithelial cells : B, 
of nucleated epithelium. Both forms occurred at different parts 
of the surface of the tumour. All the epithelial cells had a 
puckered appearance. Magnified 220 diameters. 
Fig. 4. Fibrous tumour of the skin (a wart). Magnified 160 dia- 
meters. 

A pedunculated wart, which had been growing for the space of two 
years in the axilla of a young man, was excised. 

After extirpation it appeared smooth, of the size and form of a 
lentil, covered with normal epidermis, and slightly corrugated. 

Its pedicle was short and thin. 

On making an accurate examination, the following appeared to be 
its true structure. The matter scraped from the surface of the wart 
formed a white, dirty powder, which, under the microscope, was seen 
to consist of very thin, roundish, oval, or angular scales, devoid of 
nuclei (A a). They were in every respect identical with the flat 
cells forming the external layer of normal epidermis. The cells 
which formed the interior epidermic layers of the tumour were 
generally smaller and less flat, and exhibited decided nuclei (A. b). 
Hence the investment of the tumour consisted of normal epidermis. 
The interior of the wart was formed of a very dense fibrous tissue 
(B), and in some spots undulating bundles of caudate fibres might 
be seen, on many of which nuclei were perceptible (C). Throughout 
this structure, there were numerous caudate cells with nuclei (D), 
representing all the stages of the development of areolar tissue ; 
which we have depicted in Plate iv. Fig. 1 and 2. 



EXPLANATION OF THE PLATES. 



565 



PLATE VIII. 

CARCINOMA SCIRRHUS COLLOID. 

Fig. I — 3. Scirrhus of the testicle. Magnified 220 diameters. 

The extirpated testis was of the size of a goose-egg, and retained 
its perfectly oval form, without any inequalities or excrescences. 
The surface turned towards the tunica vaginalis was smooth, and only 
in parts united with that membrane. The epididymis was distinct, 
and did not appear to be enlarged. On cutting through the testis, 
its whole mass was seen to have been affected by an uniform change. 
It was very firm, cartilaginous, and of a white colour. 

A microscopic examination exhibited the following results. Small 
masses that had been pared from a recent section of the tumour and 
moistened in water consisted entirely of an accumulation of cells. 
(Fig. 1.) These were very pale, varying in size and form, being 
sometimes roundish (a), sometimes oval (b), or caudate (/), or again 
of entirely irregular form. The greater number exhibited nuclei (a, b,), 
and in some a nucleolus was visible in the nucleus (c, h) ; few were 
devoid of nuclei. On some, fat-globules were observed (g). Be- 
tween these cells there were perceived nuclei with or without nu- 
cleoli (d). In places there appeared between the cells smaller or larger 
portions of dark granules — fat granules (e) ; finally, at certain spots* 
isolated nodules were observed (Fig. 3. B.) consisting of indistinct 
fibrous capsules, containing the cells already described. 

On cutting off small portions of the tumour with scissors, and 
placing them under the microscope, having moistened them with 
water, and drawn them into fibres by means of fine needles, the pale 
cells of varying size and shape, which we have already described, 
were observed. On treating them with acetic acid, they disappeared, 
leaving only the nuclei and nucleoli. On removing these cells as 
much as possible by constant washing, a tissue remained composed of 



566 



EXPLANATION OF THE PLATES. 



broad transparent fibres (Fig. 2.). These fibres entirely resembled 
those of organic muscle. They mostly disappeared on being treated 
with acetic acid when oat-like masses — nuclei — appeared (Fig. 3. A.), 
entirely similar to those seen on treating the muscidar fibres of the 
intestine or the uterus with acetic acid, These two elements — the 
cells and fibres — independently of the fat granules and crystals of 
cholesterin, which will presently be described, are the only ones 
which appear in this case. 

Fine sections made, with the double knife, in the tumour, not only 
shewed the same constituents, but led to the assumption of a similar 
arrangement of these histological elements. The fibres did not follow 
a straight course, but formed curves — parabolas, ellipses, or circles — 
which were filled with cells. This arrangement was especially evi- 
dent on the application of acetic acid, which caused the nuclei to 
come prominently forward, and the course of the fibres to be thus 
ascertained. (Fig 3. A y ) shews a part treated in this way with acetic 
acid. One portion of the fibres runs in a nearly straight direction, 
while another forms a spherical capsule filled with cells. If we examine 
these portions with a lower power we clearly ascertain that the fibres 
not only form circular meshes, but actual spherical capsules ; we 
here find fibrous nodules, without any trace of cells, which only 
appear when the spheres have been flattened by compression : or, 
when the fibres of the capsule have been made transparent by acetic 
acid, in which case the round nuclei of the inner cells distinctly appear, 
and are totally different from the elongated nuclei of the enclosing 
capsule. 

On treating a thin section of the tumour with acetic acid, an 
amorphous viscid matter coagulated. 

A small portion of the scirrhus was softened, and puriform. The 
semi-fluid, pulpy mass consisted of the remains of cells and fibres, 
neither of which were individually distinct ; the whole being dissolved 
into a semi-fluid, indefinite mass, in which many dark brownish gra- 
nules of fat were seen, partly isolated, and partly in large masses. 
Acetic acid rendered the whole mass paler, and gave it a conglo- 
bate appearance, without our being able to observe a distinct coagu- 
lation of any particular substance. 

At one part of the scirrhus we perceived very large cells, mostly with 
nuclei, and interspersed with crystals of cholesterin (Fig. 3. C). 

Certain parts of the epididymis and tunica vaginalis were scirrhous. 
These exhibited the same arrangement of histological elements. 
Fig. 4 & 5. Scirrhus of the liver. Magnified 220 diameters. 



EXPLANATION OF THE PLATES. 



567 



A young man, a soldier, had suffered for a long time from a con. 
stantly increasing swelling of the abdomen. A firm tumour with 
several hard knotty parts occupied the whole of that region, and 
could be distinctly felt. Febris hectica : Death. 

On making a post-mortem examination some purulent fluid was 
found in the abdominal cavity, while the intestines were mostly 
covered on their surface with coagulated fibrinous exudation. The 
liver was so greatly enlarged, that it extended into the pelvis, and 
occupied nearly the whole abdominal cavity. It weighed when 
removed upwards of fourteen and a half pounds. About half of this 
substance consisted of a large number (twenty or thirty) yellowish 
white nodules, of different sizes. 

The parenchyma of the liver, which lay between these nodules, 
appeared perfectly normal. The enlargement extended tolerably 
regularly over all the lobes of the liver. The tumours on the 
liver were all roundish or oval, varying from the size of a walnut 
to that of a hen's egg. They were hard and firm to the touch — 
almost cartilaginous — and exhibited a pale yellowish colour on 
being cut. A whitish yellow fluid could be expressed from the 
greater number ; in fact, in some the interior was entirely softened 
and converted into this fluid. Many of them craunched under the 
knife, and exhibited a shining fibrous structure, but no concentric 
layers could be distinguished. The scirrhous nodules had blood-ves- 
sels, which were visible even to the naked eye. They were inti- 
mately connected with the normal parenchyma, not being divided 
from it by any membrane, or peculiar histological stratum. 

A microscopic examination of these scirrhous tumours gave the 
following results : 

A. The pale yellowish fluid expressed from the cut surface of 
the tumor consisted of : 1 . Evident fat-globules of different sizes, 
partly isolated (Fig. 4. A), and partly collected together in larger 
masses (B). 

2. Larger, dark, granulated, roundish or oval corpuscles, similar 
to granular cells (Fig. 4. C). They appeared to be cells, containing 
-or covered with small fat- globules. 

3. Minute, pale, roundish corpuscles, varying from the 300th to 
the 400th of a line in diameter, (Fig. 4. D). The greater number 
had nucleoli, some a single, others a double nucleolus. These cor- 
puscles (nuclei) appeared isolated at various spots, but the greater 
number were accumulated in masses. Most were pale, while a few 



568 



EXPLANATION OF THE PLATES. 



appeared darker and more compact, and had a sharply denned 
outline. 

4. Some, although proportionately few, of these nuclei were sur- 
rounded by a pale cell- wall, (Fig. 4. D. a). 

Different chemical agents had the following effects upon them. 
Water did not change them in any way. 

On the addition of ether the fat-globules (A. B.), together with the 
granulated corpuscles (C), disappeared. They flowed together and 
united into large fat- drops ; while, by the coagulation of the albumen, 
the nucleoli and cells (D) were united in an irregular coagulated 
mass, rendering them indistinct. 

Acetic acid produced a similar amorphous coagulation, resembling 
coagulated mucus. The nuclei shrivelled, became a little smaller, 
but were more distinctly marked. The fat-globules and fat-granules 
were not affected. 

The cells and nuclei entirely disappeared in a solution of potash, 
(which had imbibed some carbonic acid from the atmosphere ;) 
nothing remaining but the granulated corpuscles (C) and the glo- 
bules of fat, which had not formed a soap with the potash, in conse- 
quence of there not being a sufficiently elevated temperature. 

B. The fibrous stroma of the tumour, after the above-named parts 
had been removed as far as was possible by washing, consisted of 
distinct, broad, parallel fibres (Fig. 5. A), similar to those of organic 
muscle, as they appear in the uterus and the intestinal canal. They 
were firmly united together in membranous masses, in which it was 
difficult to distinguish the individual fibres (Fig. 5. B) ; indeed, at 
places, the substance appeared, although firm and compact, perfectly 
amorphous, without any trace of fibres ; and the nuclei were so 
firmly deposited in it, as not to be removable by washing (Fig. 5. C.) 
Here, therefore, the nuclei appear to lie in an amorphous substance. 
In places, other fibres consisting of caudate cells with distinct nuclei, 
ranged one close to the other (Fig. 5. D), lay between the above- 
named band-like fibres (Fig. 5. A.) These caudate fibres formed 
separate groups, but were of comparatively rare occurrence. There 
was unfortunately no examination made of the relations of these dif- 
ferent fibres to chemical reagents. 

Thin sections of the unwashed tumour showed that the fat-globules 
(Fig. 4. A. B), the granulated bodies (Fig. 4. C), and the nuclei 
(Fig. 4. D), besides small crystals of ammoniaco-magnesian phos- 
phate (probably originating subsequent to death) were all deposited 



EXPLANATION OF THE PLATES. 



569 



in the interstices of the fibrous bundles. In some places the fibres 
preponderated ; in others, as in the softer parts, the fat-globules were 
most frequent ; and again the nuclei in others. The fibres did not 
exhibit any decided order of arrangement. 

Fig. 6. and 7. Softer cancer (encephaloid) of the knee-joint. Mag- 
nified 220 diameters. 

A young man suffered from considerable swelling of the left knee. 
The extremity, from the knee downwards, was much emaciated. 
There was also general emaciation of the whole body, and hectic 
fever. On the dorsum of the right foot there was a (scrofulous ?) 
ulcer. 

The diseased knee had increased to twice the normal size, and the 
tumour yielded on touch a deceptive sensation of fluctuation ; the 
skin was somewhat tense, but not in any degree discoloured. The 
leg was amputated by Professor Stromeyer, at the lower third of the 
femur, and handed to me for examination immediately after the 
operation. 

On laying open the knee-joint, it was evident that the disease was 
seated principally in the synovial membrane and in the adjacent 
adipose tissue. The synovia was not increased. There was no 
trace remaining of the actual synovial membrane ; excepting where 
it covered the cartilage of the joint, it was changed into a grayish 
red mass, which was very soft, having the consistence and appearance 
of ordinary adipose tissue. It differed however from the latter in being 
of a reddish- gray colour. The surrounding adipose tissue was changed 
in the same manner, in some spots to the thickness of half an inch 
and more ; while in other places, this difference did not extend beyond 
the depth of two or three lines. The altered synovial membrane 
and adipose tissue resembled each other so perfectly, that no limits 
could be discovered between them, as they merged directly into one 
another. In the degenerated mass there were many softened parts, 
about the size of a pea or bean, containing a dingy whitish-yellow, 
thickish, puriform fluid. They were scattered throughout the whole 
structure, without any definite arrangement, and it was only in a few 
places that the adipose tissue appeared to be normal in the immediate 
vicinity of the synovial membrane. It was evident that the 
quantity of adipose tissue was very great in the vicinity of 
the diseased joint, in proportion to the general emaciation of 
the rest of the body. The cartilage of the patella, as well as 
that of the articulation of the os femoris and tibia appeared 
perfectly normal. A section of cartilage from the outer surface of 



570 



EXPLANATION Of THE PLATES. 



the patella was examined under the microscope ; the cartilage -cor- 
puscles, as well as the intervening intercellular substance, exhibited 
the usual characters, excepting that most of the cartilage- corpuscles 
contained many fat- globules. The free surfaces of the cartilage were 
almost everywhere covered with a thin membranous layer, which 
could easily be torn into shreds which appeared gelatinous, of a 
yellowish- gray dingy colour, and were about the thickness of letter- 
paper. The different parts of the tumour were then microscopically 
examined. 

1. The thin layer on the outer surface of the cartilage appeared 
perfectly amorphous, similar to coagulated fibrin, without vessels or 
any trace of fibres, of areolar tissue, or of epithelium. Isolated cells 
were visible, most of which resembled those described in Fig. 6. A; 
others had a very thick cell-wall and granular contents, with a 
nucleus (Fig. 6. B ) ; others, again, contained several nuclei, 
(Fig. 6. C). On the addition of acetic acid, the amorphous mem- 
branous mass became perfectly transparent, and many nuclei came 
prominently in view. It was, therefore, doubtlessly a blastema in 
the act of developing itself into a cancer. 

2. The pale yellow puriform matter which appeared in the above- 
mentioned softened parts of the degenerated portion, contained 
numerous cells in a colourless fluid. These cells were roundish or 
oval ; the smaller varied from the j 200th to the 300th of a line in 
diameter (Fig. 6. A. a.) ; indeed some (d) were even smaller, (these 
were, however mere nuclei, measuring only about the 400th of a line ;) 
the larger measured the 100th or even the 80th of a line in their 
longest diameter. Most of these cells were covered with granules 
(fat ?), and many exhibited a distinct nucleus and nucleoli; besides 
these cells there were isolated blood-corpuscles (Fig. 6. A. c. ; the 
Plate shows them edgeways), and many fat-granules. 

The fluid coagulated on the addition of acetic acid, the walls 
becoming very pale (Fig. 6. D. a), or entirely disappearing. The 
nuclei of the cells appeared more distinctly (Fig. 6. D), and were 
nil single, and easily to be distinguished from the nuclei which appear 
on treating pus -corpuscles with acetic acid. The dark granules on the 
cells were not changed by the acid, (E.) 

Caustic ammonia did not alter the fluid, but rendered the cell- 
walls, as well as the nuclei, pale, and finally caused them to disappear. 
The dark granules covering the cells were not affected by the 
ammonia, but came more distinctly in view (Fig. 6. E.) 
ii • With respect to the chemical character of the fluid in which the 



EXPLANATION OF THE PLATES. 



571 



cancer- cells were suspended, microchemical experiments yielded the 
following results. 

Nitric acid produced a very copious, almost amorphous, whitish 
coagulum, which enclosed the cells (albumen) ; the cells themselves 
were not changed. 

On the addition of ether, a copious coagulation of an amorphous 
dark matter (albumen ?) appeared ; the dark granules adhering to the 
cells were mostly dissolved, (fat). 

Bichloride of mercury gave a very copious coagulum of an amor- 
phous colourless mass, which enclosed the cells, (albumen). 

Infus. Gallarum yielded also a very copious coagulum, partly amor- 
pho-granular, of a brown colour (albumen), and partly altogether 
amorphous and colourless (extractive matter). The cells were 
enclosed in this coagulum. 

Nitrate of silver gave a very copious coagulum ; partly a black 
granular mass (chloride of silver), and partly dark-brown, perfectly 
amorphous masses, (albumen). 

Acetic acid coagulated a moderate quantity of amorphous matter, 
(pyin ?). 

Alumina yielded a moderate coagulum, about the same quantity 
as that given by acetic acid, and less than that by the agents which 
coagulate albumen. The mass was perfectly amorphous and colourless, 
and enclosed the unchanged cells. 

The proper cancer-matter was of a grayish-red colour, and re- 
sembled adipose tissue ; it contained evident blood-vessels, which run- 
ning curvilinearly formed irregular meshes. The same cells appeared 
in this tissue which have been described as occurring in the softened 
parts. (Fig. 6, A). A portion of the fluid coagulated, on the 
addition of acetic acid, into an amorphous colourless mass. When the 
cells had been removed by pressure and washing, the stroma of 
the tissue remained, as an amorpho-fibrous substance disclosing on 
close investigation band-like fibres running in parallel directions, 
(Fig. 7, A) and perfectly resembling those of organic muscle. They 
were especially evident on the free edges. On treating the tissue 
with acetic acid these fibres became very pale, and nuclei, either 
oval with nucleoli, or elongated, acuminated, and oat- shaped (Fig. 
7, B a) appeared in them. The whole amorpho-fibrous mass 
became transparent in acetic acid, and showed (even in those places 
where the individual fibres could not be distinctly defined) many 
elongated nuclei ranged in parallel rows, (Fig. 7, B b). We hence 
see that even these apparently amorphous portions are formed from 



572 



EXPLANATION OF THE PLATES. 



similar fibres. The fibres run in a parallel direction and tolerably 
straight for short distances, but no regular arrangement could be 
perceived on a large scale. The cells were interspersed, often in large 
groups, between the fibres ; the fibres predominating in some parts, 
and the cells in others. Occasionally the cancer strikingly resembled 
in its external appearance normal adipose tissue, but microscopic 
investigation only exhibited the elements already described — fibres 
and cells — interspersed with many small globules of fat. The tran- 
sition of the cancerous into the healthy tissue was very gradual. On 
examining a portion of the adipose tissue from the vicinity of the can- 
cer, it appeared at first sight, even under the microscope, to be per- 
fectly normal ; nothing being discernible but the ordinary fat-cells 
reticulated with vessels ; but when the fat was removed as much as 
possible from the cells by means of pressure and repeated washings 
in water, there remained a residuum, which consisted only in a very 
small degree of the normal constituents of adipose tissue, being 
principally composed of newly formed cancer-fibres, (Fig. 7). In 
this, which was certainly the earliest portion of the cancer-matter, 
it was evident that the fibres were formed from elongated fusiform 
cells, like the fibres of organic muscle. 

Cells of this sort, whose nuclei and nucleoli were rendered very 
distinct by acetic acid, appeared in large quantities, sometimes 
isolated, sometimes united in groups, in the residuum of the adipose 
tissue, (Fig. 7, C). In other parts there were evident cancer-cells 
(Fig. 6, A) deposited between the normal fat-cells together with the 
cancer-fibres. 

A portion of the degenerated mass from the vicinity of the synovial 
membrane was submitted to a chemical investigation, which, how- 
ever, was unfortunately interrupted. The only results obtained 
were that 1000 parts of fresh cancer- matter yielded 171 parts of 
solid constituents, and 829 parts of water and other volatile constitu- 
ents, at a temperature of 212°, and that the whole mass was rich 
in fat. 

Fig. 8. Cancer-cells from a scirrhous breast. Magnified 220 diame- 
ters. 

The cancer contained a few of the fibres delineated in Fig. 5, A 
and Fig. 7, A, between which were interspersed many nuclei (Fig. 
8, A), and perfect; cells, (Fig. 8, B). The club-like extremities of the 
milk- ducts appeared quite unchanged in the midst of the cancer- 
mass. 

Fig. 9. Elucidates the origin of scirrhus. Magnified 220 diameters. 
The man whose scirrhous testicle was described in the explanation 



EXPLANATION OF THE PLATES. 



573 



of Fig. 1 — 3 died after the wound occasioned by the operation had 
nearly healed. 

On dissection scirrhous deposits were found in both lungs, in the 
liver and in the spermatic cord of the right side where the testis had 
been extirpated. A deposition of scirrhous matter with a knotty 
surface was found upon the vertebral column, surrounding the aorta, 
about a hand in breadth, and from two to three inches in thickness, 
reaching from the promontory of the sacrum almost to the dia- 
phragm. 

An accurate examination of these scirrhous portions gave the fol- 
lowing results. 

The scirrhous masses in the lung were tolerably denned, roundish, 
varying from the size of a hazelnut to that of a chesnut, tolerably 
compact, and firmer than the surrounding tissue of this lung ; a section 
presented a dark reddish brown colour with light and dark stripes, 
giving the cut surface a veined appearance. Under the microscope these 
parts appeared as an indistinct uniform mass, devoid of any trace of 
the true pulmonary tissue. When these portions were treated with 
ammonia the normal fibrous bundles of the pulmonary tissue distinctly 
appeared, and it was thus made evident that the scirrhous mass was 
deposited in the normal tissue of the lung, and filled up all its 
interstices. The scirrhous portions of the lungs contained no 
air. The mass appeared in most places perfectly amorphous and 
structureless (Fig. 9, B a), exhibiting, however, incipient cell- 
formation (Fig. 9, B) : nuclei with and without nucleoli being distinctly 
visible. Around these were pale cell- walls, which were more or less 
clearly separate from the surrounding blastema and sometimes 
scarcely to be distinguished from it. In some places the cells 
appeared numerous, and collected in large groups (Fig. 9, A), while 
in others they were isolated, (Fig. 9, B). A thick cell- wall with a 
double outline was very distinctly visible in some of the larger cells (as 
in B). Elsewhere broad fibres appeared in the amorphous mass, 
which, on being treated with acetic acid, became paler and exhibited 
elongated nuclei (as in Fig. 7, B, but more faint and indistinct). 

Some of the scirrhous nodules exhibited a more developed scirrhous 
structure : some caudate cells with nuclei in the act of transition into 
scirrhous fibres are exhibited in Fig. 9, C. 

The scirrhus of the liver was situated immediately under the 
peritoneum on its upper convex side : it was round, of the size of a 
small apple, tolerably compact and yet fragile, exhibiting internally a 
reddish brown colour, interspersed with whitish and bluish portions. 



574 



EXPLANATION OF THE PLATES. 



It shewed under the microscope, besides normal hepatic cells, pale 
cancer cells, similar to those depicted in Fig. 4, D, and numerous 
caudate cells (Fig. 9, C — scirrhous fibres in the act of development.) 
When these elements were perfectly removed, a tolerably large and 
firm mass remained. This was whitish, compact, and not easily 
separable into fibres. It, in part, formed perfectly amorphous un- 
defined spherical particles, varying in size from the 100th to the 
20th of a line in diameter, and, at other places, fibrous masses in which 
the scirrhus fibres were more or less plainly to be seen. The mass 
became quite pale in acetic acid, disappearing almost entirely, and 
shewing only a few nuclei. Hence the blastema appeared to be 
still almost entirely unorganized. 

The mass lying upon the aorta had the same appearance as the 
scirrhus of the liver. It was firm, and a section was reddish 
brown with white specks : the separate portions were roundish, 
nodular, and in some cases softened in the centre. A microscopic 
investigation shewed distinct blood-vessels, much fat, (partly in glo- 
bules, partly in granules, and crystals of cholesterin,) isolated cells with 
nuclei, and, as a stroma, a firm compact mass, which, acting in part 
as a blastema, contained cells and nuclei, and in part was perfectly 
amorphous, or merely exhibited an imperfect formation of large cells 
with thick walls (Fig. 9, B). In some places the amorphous stroma 
of the tissue was composed of spherical masses from the 10th part 
of a line in diameter, or even less, exhibiting, in their interior, 
decided traces of incipient cell-formation (as in Fig. 9, B). 

On treating them with acetic acid, they became perfectly trans- 
parent, and exhibited at spots elongated nuclei, similar to those 
occurring in the fibres of organic muscle — hence they were fibres in 
the process of development. 

A softened portion in the interior of one of the scirrhous nodules, 
contained cancer- cells, some of which were partially disintegrated, 
many fat-globules, and some crystals of cholesterin ; it was inter- 
sected by numerous fibrous arches and bands, which had withstood 
the influences producing the softening, and consisted of scirrhous 
fibres. 

Fig. 10. Fibrous stroma of scirrhus ; copied from Miiller, Plate ii. 
Fig. 1. 

" Meshes formed by the bundles of fibres of carcinoma reticulare 
of the breast, as they appear after the globules are removed." 
Fig. 11. Cells of carcinoma alveolare (colloid) of the stomach. Mag- 
nified 100 diameters. From Miiller, PI. n. Fig. 3, a. 



EXPLANATION OF THE PLATES. 



575 



PLATE IX. 

ENCYSTED TUMOURS MELANOSIS. 

Fig. 1 — 3. Show the histological elements of an encysted tumour, 
about the size of a nut, which was situated beneath the skin, im- 
mediately in front of the left ear of a young man, and was extir- 
pated by Breschet in the summer of 1839. Magnified 220 
diameters. 

The matter contained within the cyst of this tumour, was a thickish 
fluid substance, somewhat resembling boiled groats, of a yellowish 
white colour, and possessing a strong acid reaction. When ex- 
amined beneath the microscope it was found to consist : — 

1. Of pale very transparent cells, somewhat plicated, and from the 
50th to the 100th of a line in diameter, (Fig. 1, A) . The majority of 
them contained very pale nuclei. These cells underwent no change on 
the addition of acetic acid or ether, but by caustic potash they were 
gradually rendered more pale, and were eventually entirely dissolved. 
They formed the chief ingredient of the substance with which the 
cyst was filled, constituting about two- thirds of the entire mass. 

2. Of tabular rhomboidal crystals of cholesterin, (Fig. 1, B) which 
were not affected by acetic acid or by caustic potash, but were soluble 
in ether ; these crystals constituted about a fourth part of the sub- 
stance. 

3. Of small round corpuscles, about the 250th of a line in diame- 
ter, (Fig. 1, C) resembling in form and general appearance pus- 
corpuscles and the cells of the undermost layers of the epidermis. 
On the addition of acetic acid the cell- walls of these corpuscles were 
rendered pale, and by degrees became completely dissolved ; upon 
which a single or double nucleus in each corpuscle was brought into 
view. In this respect also they resembled pus- corpuscles. There 
was a tolerably large number of these corpuscles interspersed between 
the large pale cells already described. 



576 



EXPLANATION OF THE PLATES. 



The membrane composing the cyst within which the soft mass of 
the tumour was enclosed, appeared at first sight to be about as thick 
as the back of an ordinary knife, and to consist of but one layer ; but 
upon closer examination it was found to admit of separation into two 
distinct laminae. The inner of these layers, which was the thicker 
of the two, was of a white pearly lustre, very pliable, and entirely 
composed of the large pale cells previously described, and of a few 
scattered crystals of cholesterin ; consequently it was merely a con- 
densed outer layer of the contents of the cyst, and did not form any 
part of the true cyst itself. The outer of the two layers, which was 
in reality the cyst, had a thickness not greater than that of letter- 
paper, and was soft and extensible. When examined microscopically 
it was observed to be composed of areolar tissue, the fibres of 
which were arranged in fasciculi crossing each other in every di- 
rection, and intimately woven together in the ordinary manner 
(Fig. 3), 

The internal surface of this membrane or cyst, was lined by a 
distinct epithelium composed of flat cells arranged together in a 
tesselated manner ; the nuclei of these cells were distinctly brought 
into view on the addition of acetic acid (Fig. 2). 
Fig. 4. The contents of an encysted tumour about the size of a hen's 

egg, which was situated in front of the right ear of a female, and 

extirpated by Prof. Wilhelm. Magnified 220 diameters. 

The cyst by which the substance of the tumour was surrounded 
consisted of a smooth membrane, the thickness of which was the 
same as that of letter-paper. When examined beneath the micro- 
scope, it was found to be made up of bundles of fibres of areolar 
tissue, (as in Fig. 3) densely woven together, so as to produce a 
compact membrane. Several blood-vessels were also distinctly 
observed traversing this membrane. On its internal surface it 
was lined by a layer of epithelium similar to that represented in 
Fig. 2. 

This cyst contained in its interior a soft, grumous, very friable 
substance of a whitish colour. When examined beneath the micro- 
scope it was found to consist : — 

1. Of a large quantity of colourless oval cells (Fig. 4, a) unpro- 
vided with nuclei; these cells formed the chief ingredient of the 
mass. 

2. Of tabular crystals of cholesterin in tolerable quantity, (Fig. 
4, b). 

3. Of amorphous colourless granules of various sizes (Fig. 4, c). 



EXPLANATION OF THE PLATES. 



577 



A chemical analysis of the contents of this cyst gave the following 
results : 

Water (with a trace of butyric acid) „ . 751 

Fat (cholesterin and butyrin in about equal pro- 



portions) . . , . 38 

Alcohol- extract, with lactic acid. . „ 92 

Water- ex tract . . . ,27 

Dry cellular substance (probably with a trace of 
■ albumen) . ... 92 

Fixed salts . ... a trace 



1,000 

It would appear from the above analysis that the granules described 
in (3) consisted of butyrin. 

Fig. 5 — 7. Illustrate the epigenesis of black pigment — melanosis, 
The figures are magnified 220 diameters. 

Fig. 5 and 6. Newly formed black pigment from beneath the peri- 
toneal coat of the intestines ; from an aged woman who died from 
marasmus. 

The intestinal canal was at various points covered with organized 
false membranes ; it was externally of a greenish-black colour, and 
throughout its course presented several constrictions. On removing the 
serous coat it was found to be colourless ; the pigment being depo- 
sited in the muscular coat. On placing a portion of this tissue 
under the microscope, roundish and intensely black granules varying 
from the 1200th to the 500th of a line in diameter (Fig. 5) were seen 
deposited in a colourless mass. These black granules were unaffected 
by acetic acid, which indeed by rendering the adjacent parts more 
transparent, brought them more prominently into view. A solution 
of potash did not alter them. On the addition of nitric acid, a large 
amount of albumen coagulated, and obscured the whole object % 
hence it could not be determined with certainty whether the granules 
were soluble in nitric acid. 

The pigment-granules were collected in heaps and groups, the 
portions of parenchyma lying between them being more or less free 
from melanosis (Fig. 5 and 6). The pigment- granules were, in this 
case* not enclosed in cells. 

At some parts there was a tolerably deep yellow-green coloration of 
the parenchyma (Fig. 6) between the black spots. This colour did 
not depend on the granules, but appeared to be dependant on a satu- 
ration of the tissue with a coloured fluid. 

vol. i. p p 



578 



EXPLANATION" OF THE PLATES 



This case should probably be classed amongst those of false mela- 
nosis, where the formation of black pigment depends on a purely 
chemical process. 

Fig. 6. Melanosis of the intestinal villi. 

A powerful man — a trumpeter — who only two days before his 
death, was discharging the duties of his office, died suddenly from 
perforation of the intestines, in consequence of typhous ulcers. 

The whole mucous membrane, both in and between the valvula 
conniventes was strewed with greenish black points, which could not 
be removed by washing. Beyond this, nothing abnormal was ob- 
served, the mucous membrane being rather pale than reddened. 

On instituting a microscopic examination, it appeared that this 
black colour existed in the villi, which, in their interior, near the 
extremity, nearly all contained a black granular pigment. These 
granules were insoluble in acetic acid, and in caustic potash (Fig. 6). 
The mucous membrane and the villi were altogether destitute of epi- 
thelium. 

This black spotted appearance extended throughout the whole 
course of the ileum, as far as the ileo-caecal valve ; beyond this point 
there were no more black spots, but the mucous membrane at 
places had blackish-green patches, which gradually lost themselves 
in the pale, almost white colour of the surrounding surface. The 
microscope shewed that the cause of this coloration was a deposition 
of irregular black granules under the mucous membrane. The epi- 
thelium was here perfect. 

This, also, was probably a case of false melanosis. 
Fig. 7. Development of black pigment in cells ; from the lungs of a 

man who died from pleuritic empyema. 

The right pleura was filled with a fluid exudation, consisting of 
serum with pus-corpuscles, and its walls were invested with thick 
fibrinous deposits. The right lung was much compressed, was 
drawn upwards and backwards, and externally presented a slate- 
coloured appearance. The inferior lobe was solid, tough, and 
fleshy ; a section presented a grayish black colour, merging into a 
violet tint. 

Under the microscope no air and very little blood were perceptible ; 
on the removal of the latter, the pulmonary tissue appeared tolerably 
normal. Patches of black pigment, and fibrous bundles of pulmonary 
tissue were seen, the net- work at the borders being perfectly free. 
The only abnormal constituents were cells containing intensely black 
pigment (Fig. 7) ; they were strewed in considerable numbers through 



EXPLANATION OF THE PLATES. 



579 



the pulmonary tissue, but never occurred in groups. These cells 
likewise occurred in the fluid expressed from a fresh section of the 
lung. On the addition of acetic acid, the walls of the cells became 
pale and gradually vanished ; the pigment- granules were, however, 
unaffected. 

This is a case of true melanosis, in which the pigment is developed 
in its proper cells. 

Fig. 8 and 9. Walburga S. aged 27 years, a servant, entered the 
Munich Hospital on the 23rd of May, 1840. She had felt unwell for 
several days, and on admission had severe fever, diarrhoea, congestion 
of the head and chest, and difficult respiration. In a few days she 
presented a well-marked case of typhus ; the lungs were considerably 
affected, there was tumefaction of the parotid glands, and on the 
3rd of June she died. Shortly before death both arms became gan- 
grenous, the right originating from a venesection-wound made at 
an early stage of the disease, and the left without any apparent 
cause. 

An examination made twenty- four hours after death yielded the 
following results : — 

The examination of the contents of the cranium presented nothing 
abnormal. 

The left parotid was inflamed ; its tissue appeared of a violet 
colour, with minute ecchymoses. From this inflamed tissue, mi- 
nute masses could be expressed, (the size of a pin's head or less,) 
of a yellowish white colour, soft and semi-fluid These appeared to 
be pus, but when examined under the microscope, exhibited no 
trace of pus-corpuscles, and appeared to be only the blastema 
for the formation of pus ; they were amorphous, but contained fat- 
globules and minute granules (margarin) together with a few epi- 
thelial cells from the salivary ducts. On the addition of acetic 
acid the amorphous mass instantly disappeared ; nothing remaining 
but the nuclei which resembled those of pus -corpuscles. 

The lower lobes of the lungs were infiltrated with bloody serum ; 
the bronchi were reddened and filled with a frothy fluid. 

The mucous membrane of the stomach was soft and easily pulled 
off; at the lower part of the small intestines there were several 
plaques and small ulcers. 

The mesenteric glands were slightly enlarged. 

There was gangrene in both arms. 

On the left side, from the back of the hand to four inches above 
the bend of the arm, the subcutaneous cellular tissue was reddened 

p p 2 



580 



EXPLANATION OF THE PLATES. 



This redness penetrated to the bone and was associated with serous 
infiltration of the tissues. The muscles were also changed, being soft, 
viscid, and easily torn. 

Muscular tissue from the middle of the forearm was examined 
under the microscope. It was of a grayish red colour, and very 
soft, The primitive fibres of the muscles retained their normal form, 
but they were very pale, transparent, gelatinous, and without any 
trace of their normal transverse stria (Fig. 8). The cellular tissue, 
however, still retained its normal relations, showing the usual curved 
fibrous bundles. Between the muscles and the cellular tissue there 
were numerous fat- globules. There was no trace of blood corpuscles ; 
they appeared to be wholly dissolved. 

The same relation was exhibited by parts from other muscles 
of the fore- arm. The primitive fibres were pale, gelatinous, and 
without any trace of being striated, but the cellular tissue was 
normal. The blood- corpuscles had everywhere disappeared, while 
the fluid which saturated the whole of the tissue was of an uniform 
red colour. 

On the right arm the subcutaneous tissue was also inflamed, espe- 
cially in the vicinity of the wound previously mentioned ; showing very 
considerable and numerous ecchymoses and incipient gangrene. The 
muscles were somewhat less soft, and less easily torn than in the 
left arm. 

In the adipose cellular tissue, infiltrated with blood, blood-corpuscles 
were seen under the microscope partly dissolved, and partly still 
present, but all changed (spherical, dentated, and indistinct). The 
greater number of the fat-cells contained groups of crystals of mar- 
garin. The primitive muscular fibres appeared pale, and in parts 
striated, while in other portions this appearance was wanting. 
(Fig. 9). 

Fig. 8. Exhibits primitive fibres of muscle, softened by gangrene, 
whose striated appearance was quite lost. They are covered with 
numerous fat-globules (on the left arm). 

Fig. 9. Shows primitive fibres of muscle softened by gangrene, taken 
from the right arm. They are pale, the striated character still 
discernible in some parts, but wanting in others ; their destruction 
is therefore not so far advanced as those delineated in Fig. 8. 
Both figures are magnified 220 diameters. 

Fig. 10. Exhibits gangrene with extravasated and decomposed blood. 
Magnified 220 diameters. 

In this figure a mass of decomposed blood from a partially 



EXPLANATION OF THE PLATES. 



581 



gangrenous spleen, with black granules, (pseudo-melanosis,) is repre- 
sented. 

A man died from tubercles in the lungs, with perforation of the 
pleura and effusion of the softened tubercular mass into the pleural 
cavity. 

He had exhibited no symptoms of derangement of the spleen; it 
was, however, larger than common, of a slate colour on the outer 
surface, and partially covered with old false membranes. In some 
places irregularly oval, yellowish white specks about the size of a 
bean were visible, presenting the appearance of tubercles shining 
through the fibrous membrane. 

On cutting the spleen through the centre, it appeared normal, but 
rather soft. The external edge was of a dark bluish black colour ; 
the coloration penetrating at some points only one or two lines in 
depth, and at others seven or eight lines ; in those places which 
appeared externally as yellowish white specks, the dark tint extended 
to the greatest depth. 

The spleen emitted a fetid gangrenous odour. 

The red portion of the spleen, with the exception of being rather 
soft, was quite normal. It was very full of blood, and when this was 
removed by washing, normal spleen- corpuscles appeared (caudate cells, 
filaments with nuclei lying on them), which formed the parenchyma 
of the spleen without there being any intervening substance. When 
they were dissolved in ammonia, nothing remained but the vessels, 
and the fibrous bundles in the stroma of the spleen. 

The black substance on the edge of the spleen was very soft, and 
admitted of being easily reduced to a pulp. Where it occurred 
in thin layers, it consisted of an accumulation of intensely black 
granules, which were irregularly round, and varied from the 400th to 
the 800th, or even 1000th of a line in diameter ; and were neither 
dissolved or in any way altered by acetic acid, water, ammonia, or 
nitric acid. In some parts the black matter was so thickly crowded 
together that no individual granules could be discerned. 

Where the black coloration penetrated deeply into the interior, 
larger or smaller portions of decomposed blood were found in the 
tissue of the spleen, forming coagulated masses of a yellowish, or 
blackish brown colour, such as are commonly met with in gangrene. 
Between them there were black (melanotic) granules in large quan- 
tities (Fig. 10). 

a a are portions of decomposed blood — b b are the melanotic 
granules interspersed between them. 



582 



EXPLANATION OF THE PLATES. 



Fig. 1 1. The histological constituents of enchondroma. This figure 
represents a portion of enchondroma of the hand, with partial 
ossification. Magnified 220 diameters. 

This preparation is in the Pathological Museum of Clinical Sur- 
gery at Erlangen, where I examined it in the summer of 1841. I 
am indebted to the kindness of Dr. Herz for the following notice of 
the patient, the operation he underwent, and the tumour on its first 
examination. 

George Spoerl, a peasant from Schleifhausen near Erlangen, aged 
thirty-four years, of a healthy family, and having himself enjoyed excel- 
lent health, came to the School of Clinical Surgery, at Erlangen, in 
the autumn of 1839, with a tumour on the last joint of the right 
thumb. Two years previously, several small pisiform excrescences had 
appeared upon it, which were not at first stationary, but became 
gradually larger, until they covered the whole volar surface of the 
phalanx. 

The skin covering them was at first normal, but it subsequently 
became red and discharged slightly ; after which the patient 
suffered violent pain. He had used the thumb constantly when at 
work, and ascribed the aggravation of the disease to this circum- 
stance. On examination, it was found that the volar surface of the 
last phalanx of the thumb was covered with a tumour, of the size of 
a walnut, consisting of uneven separate tuberous divisions, varying 
from the size of a pin's-head that of a pea or a hazel-nut, rounded 
off and well defined. The tumour covered by the reddened and dis- 
tended skin had a smooth porcelain-like appearance. It was 
immovable, and firmly seated upon the bone, while the upper nodules 
were cartilaginous to the touch, their base being firmer and more 
osseous. While the joint was still free, the upper phalanx was 
removed. The wound healed without any difficulty. An examina- 
tion after its extirpation shewed that the tumour consisted of sepa- 
rate divisions, which were cartilaginous above and on the sides ; there 
being only isolated bony particles to be felt in the interstices. The 
base was osseous ; it was not, however, immediately attached to the 
phalanx, but separated from it by the periosteum. The tumour had 
penetrated in two places into the phalanx, which was consequently 
excavated at those parts. Firm membranous bands passed from the 
tumour to the phalanx, and their insertion could only be recognized 
after a careful preparation of the parts. The remaining parts were 
normal, but the whole phalanx thinner, excepting at the places of 



EXPLANATION OF THE PLATES. 



583 



insertion. The patient has had no relapse up the present time 
(July, 1842). 

This tumour exhibited several deviations from ordinary enchon- 
droma. It did not originate in the phalanx itself, but was divided 
from it by the periosteum. It consisted, further, only in part of carti- 
laginous matter, analogous to that of ordinary cartilage ; a. a. being 
cartilaginous cells in an amorphous intercellular substance (A. A.) ; 
of which a portion (B. B.) was ossified and converted into true 
bony substance. It was of the hardness of bone, effervesced freely 
when immersed in hydrochloric acid (from the decomposition of 
carbonate of lime), and exhibited perfectly developed bone- corpuscles 
and osseous canals, surrounded by cylindrical, concentric laminae. 



584 



EXPLANATION OF THE PLATES. 



PLATE X. 

CONCREMENTA EPIPHYTA EPIZOA. 

Fig. 1 . Shows the crystalline deposition of cholesterin in atheroma 
of the aorta. Magnified 220 diameters. 

An old man, aged eighty-four years, who had died from a per- 
forating ulcer in the stomach, exhibited a deposition of calcareous 
salts (false ossification) in the arch of the aorta, between its inner 
and middle coats, besides a deposition of a yellowish- white greasy 
mass, (atheroma). This soft mass was found to consist of the fol- 
lowing elements, when examined under the microscope : — 

(1) . Of many tabular colourless crystals of cholesterin, of the 
ordinary characteristic form, (rhomboidal tablets with angles mea- 
suring 103° and 77°). 

(2) . Of many irregular amorpho-granular masses, which did not 
dissolve in water, but were soluble in alcohol ; after the evaporation 
of which, they again thickened into amorphous brownish clots — pro- 
bably fat. 

Besides these elements and some few fat-globules (3), nothing 
was present. 

Fig. 2. Crystalline deposition of calcareous salts in the cuticle of 
the scrotum. Magnified 220 diameters. 

A healthy man, aged thirty-three years, a baker by trade, had 
suffered from pruritus of the scrotum, from about his eighteenth 
year. There had gradually appeared upon the scrotum small wart- 
like excrescences, which after they had attained the size of a pea, 
dried up and disappeared ; after which, new formations appeared in 
other parts, which again underwent the same change. This process has 
continued to the present time, (March, 1841), without much incon- 
venience to the patient, or the slightest influence upon his general 
health. 



EXPLANATION OF THE PLATES. 



585 



A minute examination showed a number of roundish tumours on 
the scrotum, varying from the size of a pea to that of a hazel-nut, 
There were upwards of a hundred and fifty of these protuberances 
scattered over its whole surface. They were situated immediately 
under the skin, which nevertheless appeared perfectly normal, and 
not in the slightest degree discoloured. They could be moved in 
any direction with the skin. 

When these tumours were opened with a lancet, they discharged 
a pulpy, perfectly white mass, which when moistened with water, 
exhibited an alkaline reaction, and, on exposure to the air, became 
as hard as stone. This pulpy mass was found to consist, when 
microscopically examined (Fig. 2), of an indefinite finely granular 
mass, which appeared of a brownish colour by transmitted light, 
with colourless fragments of crystals, which were mostly rounded , 
but of an indistinct form, and never exhibiting any perfect shape. 

This mass was not affected by water, alcohol, ether, or alkalies; but 
dissolved in acids with effervescence. 

An accurate chemical investigation gave, as the chief constituents, 
carbonate and phosphate of lime, with a trace of chloride of sodium, 
and a slight admixture of organic matter, (fat and extractive 
matters). 

One of the tumours, together with the enclosing cyst, was removed, 
and carefully examined, in order to discover the relation of the 
deposited calcareous salts to the surrounding tissue. The whole 
cyst was so impregnated with cutaneous crystals, that nothing 
definite could be ascertained concerning its structure. The external 
layer of the cyst, which was free from calcareous particles, consisted 
of undoubted bundles of fibres of areolar tissue, and contained much 
blood. A portion of the cyst was treated with dilute jaitric acid, in 
order to remove the salts of lime, but nothing could be then seen 
under the microscope except fibrous bundles of areolar tissue and 
blood-vessels. 

It therefore remained uncertain whether the salts were deposited 
in the tissue of the skin, or in the cutaneous glands ; the latter is, 
however, most probably the case, since the cabareous fragments 
abraded from the inner surface of the cyst gave evidence of non- 
nucleated epithelial cells. 

Fig. 3. Crystalline depositions of margarin. Magnified 220 dia- 
meters. 

These depositions are frequently observed in the adipose tissue of 
the dead body, and probably owe their origin to purely chemical 
vol. i. ft Q 



586 



EXPLANATION OF THE PLATES. 



relations, as for instance, to a preponderance of margarin over olein in 
the human body, in consequence of which the former separates and 
crystallizes on the cooling of the body. These crystalline depo- 
sitions are most frequently met with in fatty gangrenous parts, where 
indeed they are seldom absent. 

The most frequent form of this structure is that in which the 
points of the crystals radiate round a central point in a star-like 
figure (Fig. 3. a.) ; seen sideways, this star appears like a sheaf 
(Fig. 3 *) ; sometimes two such sheaves appear united together (b) ; 
large needles occur but rarely, either isolated or decussating. 

These crystalline groups are formed within the fatty cells (Fig. 3. 
b. b), and are only liberated when the latter are destroyed. 
Fig. 4. Crystals of ammoniaco-magnesian phosphate. Magnified 

90 diameters. 

They are formed in all parts of the human body in which free 
ammonia occurs. The crystals form several modifications of one type, 
but all are hemiedric. The type (Fig. 4. a.) is a three-sided prism, 
with the corresponding angles of one of the sides truncated. 

a * shows an ideal section of this form seen sideways. This type 
changes only on the further truncation of two, polarly opposite, cor- 
responding angles (4. b.), and then by further truncating one of tl 
two remaining angles, (Fig. 4. c.) 

Fig. 5. Is apiece of soft gallstone from the human subject, given 
in order to illustrate its mechanical composition. Magnified 220 
diameters. 

The colourless portions are crystals of cholesterin ; the coloured 
part consisting also of indistinct crystallized cholesterin, coloured by 
gall-pigment. 

Fig. 6 — 8. Epiphyta — parasitic plants occurring in the human 
body. 

Fig. 6. and 7. are fungi which compose the crusts of the scrofulous 
scald-head, (Favas et Alphus, Fuchs) . 

They consist partly of roundish granules (cells) ranged one upon the 
other, and partly of elongated, single, or ramifying threads ; they are 
generally colourless, but sometimes faintly tinged with green. 
Fig. 6. is magnified 180 diameters, and Fig. 7. 400. 
Fig. 8 Exhibits the yeast plant, [Torula Cerevisia. Turpin), taken 

from a fluid ejected in large quantities by a man suffering from 

stricture of the pylorus, (hypertrophy of the muscular coat of the 

stomach). Magnified 220 diameters. 

It forms round colourless granules, or cells, which increase by 



EXPLANATION OF THE PLATES. 



587 



gemmation, and then form single or branching rows. Some have 
young cells within them (*), others increase by simultaneous gemma- 
tion and epigenesis of cells (* *) in their interior. 

These fungi are found in the urine in Diabetes mellitus. 
Fig. 9. and 10. Epizoa — parasitic animals occurring in the fluids of 

the diseased (?) human body. 
Fig. 9. The Trichomonas vaginalis ; an infusorium discovered by 
Donne, in the vaginal mucus of a woman. Magnified 300 diame - 
ters. (Copied from Donne, Recherches microscopiques sur la 
nature des Mucus, &c. Paris, 1837. Fig. 3). 
Fig. 10. Vibriones, which develop themselves in large quantities in 
all putrid animal fluids, as putrid blood, albumen, &c, and are 
scarcely ever absent from foul ulcers, (Vibrio prolifer.? Ehren- 
berg). Magnified 410 diameters. 
Fig. 11. The Sarcina vtntriculi. a. In a perfect state, b. One of 

the four-celled frustules. 
Fig. 12. The upper portion represents Fungi in Tinea favosa. 

The lower portion, tubes observed in the sputa and in tubercular 
matter. (Bennett.) 



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